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/   I 


PRACTICAL  TIIEATJSE 


URINARY  AND  RENAL  DISEASES, 


INCLUDING 


URINARY  DEPOSITS. 


ILLUSTRATED  BY  NUMEROUS  CASES  AND  ENGRAVINGS. 


BY 

WILLIAM  ROBERTS,  M.D.,  F.R.S., 

FELLOW  OF  THE  ROYAL  COLLEGE  OF  PHYSICIANS,  LONDON  ;    PROFESSOR  OF  MEDICINE  AT  THE  VICTORIA  UNIVERSITY  ; 
CONSULTING  PHYSICIAN  TO  THE  MANCHESTER  ROYAL  INFIRMARY. 


ASSISTED  BY 

ROBERT  MAGUIRE,  M.D.  Lond., 

MEMBER  OP  THE  ROYAL  COLLEGE  OF  PHYSICIANS,  LONDON  ;   PHYSICIAN  TO  OUT-PATIENTS,  ST.  MARY's  HOSPITAL,  LONDON  : 
LATE  PATHOLOGIST  TO  THE  MANCHESTER  ROYAL  INFIRMARY. 


FOURTH   EDITION. 


PHILADELPHIA: 

LEA    BROTHERS    &    CO. 

1885. 


DORNAN,  PRIKTEE. 


PREFACE. 


The  design  of  the  present  work  is  to  give  an  account  of  the  organic 
diseases  of  the  kidney,  and  of  those  diseases  and  disorders  of  which 
the  chief  characteristic  is  some  alteration  of  the  urine. 

The  work  naturally  falls  into  three  parts. 

The  first  part,  which  may  be  regarded  as  introductory  to  the  other 
two,  is  devoted  to  the  physical  and  chemical  properties  of  the  urine, 
and  to  the  various  alterations  which  it  undergoes  under  different  cir- 
cumstances of  health  and  disease,  in  so  far,  and  only  in  so  far,  as  they 
seem  to  have  a  practical  bearing.  The  methods  of  examining  the  urine 
for  clinical  purposes  are  explained;  and  the  significance  of  the  diverse 
changes  experienced  by  it  pointed  out.  The  naked-eye  and  micro- 
scopical appearances  of  urinary  deposits  are  described  and  figured, 
together  with  those  of  the  extraneous  matters  which  accidentally  find 
their  way  into  the  urine. 

Of  the  vast  array  of  researches  on  the  composition  of  the  urine,  and 
the  rate  of  excretion  of  its  several  ingredients,  accumulated  in  recent 
times,  it  has  been  found  impracticable  to  give  even  an  abstract  without 
greatly  exceeding  the  limits  of  practical  utility.  It  has  seemed  to 
the  author  more  convenient  to  consign  these  purely  chemical  and 
physiological  materials  to  separate  treatises,  in  the  manner  adopted  by 
Neubauer  and  Vogel  and  Dr.  Parkes,  at  least  provisionally,  that  is, 
until  such  time  as  they  can  be  shown  to  possess  some  clinical  value. 
Further,  these  subjects  are  treated  so  amply  in  the  works  (in  addition 
to  those  of  the  authors  just  mentioned)  of  Beale,  Thudichum,  Hassall, 


IV  PEEFACE. 

and  others,  that  the  omission  of  them  has  caused  the  author  little  regret. 
It  is  hoped,  however,  that  nothing  has  been  omitted  a  knowledge  of 
which  possesses  any  interest  for  the  actual  practice  of  medicine. 

The  second  part  treats  of  a  group  of  affections  which  may  be  desig- 
nated briefly  as  "urinary  diseases,"  viz.,  diabetes  insipidus,  diabetes 
mellitus,  gravel  and  calculus,  and  chylous  urine.  In  his  description  of 
.these  diseases  (with  the  exception  of  gravel  and  calculus),  the  author 
has  endeavored  to  present  an  analysis  of  all  the  facts  hitherto  published 
in  relation  to  them,  together  with  those  which  have  fallen  under  his 
own  notice.  In  the  chapter  on  gravel  and  calculus,  prominence  has 
.been  given  to  the  medical  treatment,  and  especially  to  the  author's  own 
researches  in  this  direction. 

The  organic  diseases  of  the  kidney  form  the  subject  of  the  third  and 
largest  part  of  the  work.  The  most  important  of  these,  Bright's  dis- 
,ease  and  its  allies,  are  treated  with  a  fulness  commensurate  with  their 
gravity  and  frequency,  and  mainly  from  a  clinical  point  of  view. 

The  less  frequent  affections  of  the  kidney — hydronephrosis,  cystic 
degeneration,  cancer,  tubercle,  parasites,  malpositions  and  malforma- 
tions are  treated  analytically,  and  at  considerable  length.  The  extreme 
poverty  of  the  older  English  systematic  works  on  these  subjects  seemed 
to  demand  this  compensation. 


The  third  edition  of  this  work  has  been  exhausted  for  some  years,  but 
I  have  been  hitherto  unable,  for  want  of  leisure,  to  undertake  the  pre- 
paration of  a  fourth  edition.  Having,  however,  obtained  the  valuable 
assistance  of  Dr.  Robert  Maguire,  this  object  has  been  accomplished. 
Dr.  Maguire  has  carefully  revised  the  entire  work  ;  and  has  brought 
up  the  several  articles  to  the  level  of  our  existing  knowledge. 


PREFACE  V 

I  have  almost  entirely  rewritten  tlic  articles  on  albuminuria  and  on 
microorganisms  in  the  urine.  Much  new  matter  has  been  introduced 
into  the  chapters  relating  to  Bright's  disease.  The  observations  of 
Bancroft,  Manson,  and  Dr.  Stephen  Mackenzie  on  the  filaria  sanguinis 
hominis  in  relation  to  the  causation  of  chyluria  will  be  found  incor- 
porated in  the  chapter  on  entozoa  in  the  kidneys. 

The  practical  aim  of  the  work  has  been  steadily  kept  in  view ;  and 
no  alterations  or  additions  have  been  introduced  which  are  not  desirmed 
to  enhance  the  clinical  value  of  the  book.  Nevertheless  an  endeavor 
has  been  made  to  give  full  references  to  pathological  researches,  with 
a  view  of  facilitating  the  labors  of  special  workers. 

W.  E. 

Manchester,  89  Mosley  Street, 
January,  1885. 


CONTENTS. 


PART  I. 

The  Physical  and  Chemical  Properties  of  the  Urine  in 
Health  and  Disease — Urinary  Deposits. 

CHAPTER  I. 

INTRODUCTORY, 


I.  Summary  of  the  properties  and  composition  of  the  urine  ;  its  physio- 
logical and  pathological  variations            .             .  .  .33 

Physiological  alterations       .             .             .             .  .  .34 

Pathological  alterations         .             .             .             .  .  .35 

II.  Methods  of  examining  the  urine — Apparatus  requned  .  .  .35 

Scheme  for  the  examination  of  the  urine    .             .  .  .36 

Apparatus      .             .             .             .             .             .  .  .37 

III.  Extraneous  matter  in  urine             .             .             .             .  .  .37 

lY.  Changes  in  the  urine  on  keeping  .              .             .             .  .  .39 

Acid  urinary  fermentation    .              .              .             .  .  .40 

Ammoniacal  decomposition  .             .             .             .  .  .40 


CHAPTER  II 


PHYSICAL   PROPERTIES    OF 


I.  Odor  .........     42 

II.  Color 42 

Normal  pigments  of  healthy  urine  .             .             .             .  .43 

Pathological  pigments           .             .             .             .             .  .44 

Derived  pigments      .             .             .             .             .             .  .46 

Adventitious  pigments          .             .             .             .             .  .47 

III.  Density  or  specific  gravity             .             .             .             .             .  .49 

Range  in  health          .             .             .             .             .             .  .49 

Clinical  significance  of  variations  in  the  density  of  the  urine  .     49 

Estimation  of  the  solids  of  the  urine  from  the  density       .  .     50 

IV.  Quantity  of  the  urine         .             .             .             .             .             .  .50 

Variations  in  health               .             .             .             .             .  .51 

Solid  urine     .             .             •             .             .             .             .  .52 

Clinical  significance  of  variations  in  the  quantity'  of  the  urine  .     53 


THE    URINE. 


Vlll 


11 

CONTENTS. 

PAGE 

V. 

Suppression  of  urine  (anuria)        .         '    .             .             .             .             .54 

Non-obstructive  suppression 

54 

Obstructive  suppression 

57 

Causes 

57 

Symptoms 

59 

Illustrative  cases 

60 

Duration  of  life  . 

74 

Treatment 

75 

VI. 

Reaction  of  the  urine 

Effects  of  food  and  fasting    . 
EflFects  of  medicine    . 
Effects  of  the  cold  bath 
Effects  of  disease 

76 
77 

.  80 
81 

.     81 

Ammoniacal  urine — Decomposition  of  urea 

.     82 

CHAPTER  III. 

CHEMICAL    CONSTITUENTS    OF    THE    URINE    AND    THEIR    VARIATIONS — INORGANIC 

DEPOSITS. 


I.  Preliminary  remarks  on  urinary  deposits  and  their  classification 

II.  Uric  acid  ... 

Naked-eye  characters 
Micro-chemical  characters 
Quantitative  determination 
Origin  and  occurrence 
Clinical  significance 

III.  Amorphous  urates 

Naked-eye  characters 
Micro-chemical  characters 
Clinical  significance 
Treatment    . 

IV.  Crystalline  urates 

Urate  of  soda 
Urate  of  ammonia 

V.  Oxalate  of  lime     . 

Naked-eye  characters 
Micro-chemical  characters 
Production  and  occurrence 
Clinical  significance 
Oxaluria 
Treatment    . 

VI.  Cystine     . 
VII.  Xanthine 

VIII.  Leucine  and  tyrosine 

IX.  Phosphoric  acid  and  the  phosphate: 

Excretion  of  phosphoric  acid  in  health  and  disease 


87 

87 

87 

90 

91 

92 

94 

94 

94 

'96 

97 

97 

97 

98 

99 

99 

100 

101 

102 

103 

105 

106 

111 

114 

115 

116 


C  O  N  T  K  N  'I'  a . 


IX 


Deposits  of  earthy  phosphates    ..... 
Amorphous  phosphate  of  lime,  or  bonc-oarlh 
Crystallized  phosphate  of  lime,  or  stellar  phosphates 
Phosphate  of  ammonia  and  magnesia,  or  triple  phosphate 
X.   Carbonate  of  lime 
XL  Sulphuric  acid  and  the  sulphates 
XII.  Chlorine  and  the  chlorides 

Supplementary  remarks  on  the  excretion  of  phc 
chlorine  .... 

XIII.  Urea         ..... 
Excretion  of  urea  in  health 
Methods  of  estimating  urea  in  urine 
Pathological  relations  of  urea 
Azoturia       .... 


osphorus,  sulphur,  and 


117 
118 
110 
121 
123 
123 
124 

124 
125 
120 
126 
130 
131 


CHAPTER  IV. 


ABNORMAL  SUBSTANCES  IN  THE  URINE:    ORGANIC  DEPOSITS. 

I.  Extra-renal  epithelium    ...... 

II.  Eenal  epithelium  and  casts  of  tubes;  the  deposits  associated  with  al 


134 


buminuria 

137 

Epithelial  casts 

138 

Opaque  granular  casts 

138 

Transparent  or  waxy  casts  . 

138 

Patty  casts    . 

139 

Blood  casts  . 

139 

Pus  casts 

139 

Clinical  significance  of  renal  epithelium  and  tube 

-casts 

141 

Tube-casts  without  appreciable  albuminuria 

142 

III.  Patty  matter  in  urine      .        ■     . 

143 

Cholesterine 

144 

Kiesteine 

146 

IV.  Pus  in  urine 

146 

Micro-chemical  characters  . 

146 

Clinical  significance 

147 

V.  Blood  in  urine — Hsematuria 

148 

Microscopic  characters 

149 

Causes  of  haamaturia 

150 

Hismaturia  from  local  lesions 

150 

Endemic  hasmaturia 

153 

Symptomatic  ha3maturia      . 

154 

Supplementary  hematuria . 

155 

Treatment  of  hsematuria 

155 

VI.  Hemoglobinuria — Paroxysmal  htemog] 

obinuria 

157 

Symptoms    . 

158 

Characters  of  the  urine 

159 

Illustrative  cases 

162 

Etiology 

166 

Pathology     . 

167 

Treatment    . 

169 

CONTENTS. 


VII.  Cancerous  and  tuberculous  matter  in  urine 
VIII.  Spermatozoa  in  urine — Spermatorrhoea 
Treatment     .... 
IX.  Microorganisms  in  the  urine 

Torulaceous  vegetations  (saccharomyces) 

Sarcina  .... 

Bacteria — Bacteruria 

Bacteruria  associated  with  incipient  putrefractive 

urine 
Bacteruria  with  ammoniacal  fermentation  of  the 
Bacteruria  without  decomposition  of  the  urine 
X.  Albumen  in  the  urine 

Albuminoid  substances 
Tests  for  albumen    . 
Quantitative  determination 
New  process  of  the  author 
Clinical  significance 
Saturnine  albuminuria 
Punctional  albuminuria 
Neurotic  albuminuria 
Pathology  of  albuminuria 
XI.  Sugar  in  urine 

Tests  for  sugar  (qualitative 

(quantitative) 
Clinical  significance 


chansre 


in  the 


PAGE 

170 
171 
173 
175 
175 
176 
177 

178 
178 
179 
185 
185 
186 
190 
191 
194 
195 
196 
197 
199 
204 
205 
213 
221 


PART  II. 


Urinary  Diseases — Diseases  of  which  the  Chief  Charac- 
teristic IS  AN  Alteration  of  the  Urine. 

CHAPTEK  I. 


DIABETES    INSIPIDUS. 


Synonyms — Classification 

Etiology 

Course  and  symptoms 

Duration    . 

Morbid  anatomy    . 

Illustrative  cases    . 

Nature 

Diagnosis  and  prognosis 

Treatment  . 

Appendix. — Cases  character: 
in  the  urine 


zed  by  diuresis,  with  slight  traces  of  sugar 


228 
224 
226 
229 
230 
280 
236 
239 
289 

241 


CONTENTS. 


XI 


CIIArTElt  II. 


I'AOB 

.  248 

.  244 

.  248 

.  253 

.  254 

, 

.  260 

)  diabetes 

.  264 

.  270 

, 

.  272 

.  286 

DIAUKTKH    MKLLITUK. 

Classification  of  cases  of  saccharine  urine 
Etiology  of  diabetes  mellitus        .    •         . 
Symptoms  ...... 

Course,  duration,  termination 

Complications         ..... 

Morbid  anatomy    ..... 

Physiological  and  theoretical  considerations  relating  to 
Diagnosis  and  prognosis    .... 

Treatment  ..... 

Appendix. — Milder  types  of  diabetes 

CHAPTEE  III. 

GRAVEL    AND    CALCULUS. 

General  etiology  .... 

Classification  of  urinary  calculi;  their  chemical  characters,  origin,  groAvth, 

and  general  clinical  history 
Of  the  particular  varieties  of  urinary  calculi 

1.  Uric  acid  calculi  . 

2.  Urate  concretions 

3.  Oxalate  of  lime    . 

4.  Cystine     .... 

5.  Xanthine 

6.  Patty  or  saponaceous — TJrostealith 

7.  Carbonate  of  lime 

8.  Basic  phosphate  of  lime  . 

9.  Mixed  or  secondarj^  phosphates  . 

10.  Fibrine  and  blood-concretions    . 

11.  Indigo      .... 

12.  Prostatic  calculi  . 
On  the  diagnosis  of  the  species  of  urinary  calculi   within   the  bla 

kidneys  ..... 
Medical  treatment  of  gravel  and  calculi  . 
A. — Preventive  treatment     . 
B. — Solvent  treatment 
Preliminary  remarks 
Solvent  treatment  of  uric  acid  calculi 
Experimental  inquiries: 

Comparison  of  potash  and  soda 

Effects  of  strength  of  solution 

Effects  of  quantity  of  solution 

Absolute  rate  of  dissolution     . 

Best  method  of  alkalizing  the  urine 

Experiments  with  alkalized  urine 

Illustrative  cases 

Discrimination  of  the  cases  to  which  the  solvent  treatment  is 

suitable     ...•.•■■ 


dder  or 


292 

294 
297 
297 
298 
299 
300 
301 
301 
308 
306 
306 
307 
309 
309 

309 
311 
811 
315 
315 
817 

317 
317 
318 
319 
319 
320 
320 

327 


XI 1 


CONTENTS. 


Rules  for  carrying  out  the  solvent  treatment 

Objections  answered  .  . 

Experiments  on  the  solvent  treatment  of  uric  acid  by  injections 
bladder         ....... 

Experiments  on  the  solvent  treatment  of  cystine  calculi 
Experiments  on  the  solvent  treatment  of  oxalate  of  lime  calculi 
Solvent  treatment  of  phosphatic  calculi 


into  the 


Characters  of  the  urine     . 
Course  and  symptoms 
Illustrative  cases   . 
Duration  and  termination 
Etiology     . 
Pathology  . 
Treatment 


CHAPTER  IV. 

CHYLOUS  URINE. 


PAGE 

329 
330 

332 
333 
333 
334 


385 
337 
338 
344 
344 
344 
355 


PART  III. 

Organic  Diseases  of  the  Kidneys. 

CHAPTER  I. 

CONGESTION  OF  THE  KIDNEYS. 

Preliminary  observations — Experimental  researches       .... 

Active  congestion  ........ 

Passive  congestion  ........ 

Appendix. — On  the  connection  of  renal  congestion,  albuminuria,   and 
Bright's  disease,  with  pregnancy  and  eclampsia  .... 

CHAPTER  II. 

bright's  disease. 
Preliminary  remarks  .  .  ■.  .  .  .  . 

General  etiology  of  Bright's  disease         ...... 

CHAPTER  III. 

acute  bright's  disease. 


Anatomical  characters 
Course  and  symptoms 
Diagnosis   . 
Prognosis    . 
Etiology     . 
Treatment . 


357 
360 
365 

371 


376 
379 


383 
386 
391 
392 
392 
393 


CONTENTS, 


CHAPTEK  IV. 


CHKONIO  hkight'h  bisjcase 

Anatomical  changes  in  the  kidneys 

1.  Smooth  white  kidney 

Synopsis  of  symptoms  and  conditions  of  origin 

2.  Granular  contracting  kidney 

Synopsis  of  symptoms  and  conditions  of  origin 
Oneness  or  multiformity  of  Bright's  disease 

3.  Lardaceous  or  waxy  kidney 

Synopsis  of  symptoms  and  conditions  of  origin 
General  course  and  symptoms 
Illustrative  cases   .... 
Particulars  of  symptoms,  and  complications 

Urine 

Blood 

Dropsy 

Skin    . 

Pulse  . 

Ketina 

Complications,  and  connection  with  other  diseases 

Bright's  disease  and  phthisis 

Bright's  disease  and  cardio-muscular  changes 
Uraemia      ...... 

General  features  .... 

Uremic  amblyopia    .... 

Convulsions  and  coma 

Distinction  of  uremic  coma  from  narcotic  poisoning  and  apoplexy 

Urseraic  vomiting  and  diarrhoea 

Ura3mic  dyspnoea 

Theories  of  ureemia 
Diagnosis    . 
Prognosis   . 
Treatment  . 


I'AOK 

396 
.396 
898 
399 
402 
403 
404 
406 
407 
409 
414 
414 
417 
417 
418 
418 
418 
419 
420 
424 
428 
429 
429 
430 
433 
433 
433 
434 
437 
439 
441 


CHAPTER  V. 

SUPPURATION    IN    THE    KIDNEY  :    RENAL    EMBOLISM. 


Phlegmonoid  abscess 
Multiple  or  metastatic  abscesses 
Eenal  embolisni     . 


449. 
451 
453 


Morhid  anatomy 
JEtiology 


CHAPTER  VI. 

PYELITIS   AND    PYONEPHROSIS. 


455, 
456 


XIV 

CONTENTS. 

PAGE 

Symptoms  . 

.     459 

Illustrative  cases   . 

.     461 

Diagnosis  . 

.     467 

Prognosis   . 

.     469 

Treatment 

.     470 

Precipitation  of  uric  acid  and  ur 
Symptoms  of  renal  calculi 
Diagnosis   . 

Treatment .  .  .        , 

Extirpation  of  the  kidney 


CHAPTER  VII. 

CONCRETIONS    IN   THE   KIDNEYS. 

(.es  in  the  kidneys  of  infants 


CHAPTER  YIII. 

HYDRONEPHROSIS. 


Morbid  anatomy 
Etiology  . 
Symptoms  . 
Terminations 
Diagnosis  . 
Prognosis  , 
Treatment 


CHAPTEPv  IX. 

CYSTS    AND    CYSTIC   DEGENERATION    OF    THE    KIDNEY. 

Scattered  cysts  in  kidneys  otherwise  healthy 
Disseminated  cysts  in  the  atrophic  form  of  B right's  kidney 
Congenital  cystic  degeneration  of  the  kidneys    . 
General  cystic  degeneration  of  the  kidneys  in  adults 


474 
475 
476 

477 
478 


479 
484 
492 
494 
494 
496 
496 


501 
502 
502 
504 


CHAPTER  X. 


CANCER    or    THE    KIDNEY. 


A. — Primary  cancer  of  the  kidney 

Morbid  anatomy 

Etiology 

Symptoms  and  physical  signs 

Duration 

Illustrative  cases 

Diagnosis 

Prognosis 

Treatment 
B. — Secondary  cancer  of  the  kidney 

Appendix. — Sarcoma  of  the  kidney 


514 
514 
518 
519 
522 
523 
538 
535 
536 
536 
539 


CONTENTS. 


XV 


CIIAPTEli  XI. 

BENIGN    GROWTHS    IN    THIS    KIDNEY. 


Osseous  growths     ...... 

Pibrous  and  flbro-fatty  growths  .... 

.     .041 

.     G41 

Lymphatic  growths                         .... 
Syphilitic  deposits             ..... 
Mixed  growths      ..... 

.  .542 
.  .542 
.     .543 

CHAPTEK  XII. 

TUBERCLE  Or  THE  KIDNEY 

Comparative  frequency  of  tubercle  in  the  kidneys 
A. — Primary  tubercle  of  the  kidney 

Morbid  anatomy 

Etiology 

Symptoms     . 

Illustrative  cases 

Duration 

Diagnosis 

Prognosis 

Treatment    . 
B. — Secondary  tubercle  of  the  kidneys 

CHAPTER  XIII. 

ENTOZOA  IN  THE  KIDNEYS. 


.544 

.544 
.544 
.546 
.540 
548 
554 
554 
555 
555 
556 


I.  Hydatids  in  the  kidney  . 
Natural  history 
Morbid  anatomy 
Symptoms     . 
Illustrative  cases 

.  558 
.  5.58 
.  561 
.  566 
.     568 

Duration 

.     571 

Termination 

.     571 

Etiology 

.     572 

Diagnosis 
Prognosis 
Treatment    . 
II.  Bilharzia  hsematobia 

.  572 
.  .S73 
.  574 
.     575 

Natural  history 
Morbid  anatomy 
Symptoms     . 
Treatment    . 

.  575 
.  576 
.  -577 
.     580 

III.  Filaria  sanguinis  hominis 

.     581 

IV.  Strongyliis  gigas 
V.  Pentastoma  denticulatum 

.  584 
.     583 

VI.  Erratic  worms     . 

.     585 

VII.  Spurious  worms  . 

.     586 

XVI 


CONTENTS. 


CHAPTEK  XIV. 

ANOMALIES  OF  POSITION,  FORM,  AND  NUMBER  OF  THE  KIBNEYS. 

PACE 

I.  Anomalies  of  position    .......     587 

A.  Fixed  malpositions  of  the  kidneys         ....     587 

B.  Movable  kidneys  ......     591 

Physical  signs  and  symptoms  ....     591 

Illustrative  cases  .  .  .  .  .  .     593 

Etiology  ,  .  .  .  .  .  .599 

Diagnosis  ...  .  .  .  .     602 

Treatment         .  .  .  .  .  .  .602 

II.  Anomalies  of  form  .......     604 

Horseshoe  kidney    .  .  .  .  .  .  .     604 

III.  Anomalies  of  number     .......     605 

Solitary  kidney        .......     605 


Bibliography 

Index  or  Subjects 
Index  of  Authors 


607 
619 
623 


PART  I. 


THE  PHYSICAL  AND  CHEMICAL  PROPERTIES  OF  THE  URINE 
m  HEALTH  AND  DISEASE-URINARY  DEPOSITS. 


CHAPTEE    I. 

INTRODUCTORY. 

I.— SUMMARY  OF  THE  PEOPERTIES  AND  COMPOSITION  OF 
THE  UEINE;  ITS  PHYSIOLOGICAL  AND  PATHOLOGICAL 
VARIATIONS. 

Healthy  urine  is  a  clear,  watery,  amber-colored,  saline  solu- 
tion, generally  acid,  with  a  specific  gravity  of  about  1020.  It  con- 
tains a  large  quantity  of  urea;  and  smaller  quantities  of  uric  acid, 
hippuric  acid,  creatine,  and  creatinine.  In  addition  to  these,  which 
are  its  characteristic  constituents,  the  urine  contains  certain 
saline  substances,  namely,  chlorides,  phosphates,  and  sulphates,  of 
which  the  bases  are  soda,  potash,  lime,  and  magnesia  ;  also  minute 
quantities  of  oxalic  and  lactic  acids,  aynmonia,  pigment,  diastase^ 
and  other  substances  which  are  classed  under  the  head  of  extrac- 
tive matters. 

All  these  substances  preexist  in  the  blood,  and  are  simply 
separated  therefrom  by  the  secerning  action  of  the  kidneys. 

The  average  proportions  of  the  chief  constituents  of  the  urine 

^  It  has  been  stated  that  traces  of  pepsin  have  been  found  in  the  urine. 
(Briicke,  Sitzimgsb.  d.  Wien.  Akad.,  Bd.  43.)  I  have  tested  several  specimens 
of  urine  with  regard  to  this  point,  but  have  invariably  obtained  negative  results. 
With  regard  to  diastase  the  case  is  different.  Healthy  urines  have  a  considerable 
power  of  changing  starch  mucilage  into  dextrine  and  sugar.  This  power  is  de- 
stroj'ed  by  heating  the  urine  to  boiling.  I  found  the  diastatic  power  of  healthy 
urine  to  vary  from  0.03  to  0.13,  compared  with  healthy  saliva  as  10  to  17.  That 
is  to  say,  speaking  roughly,  urine  has  a  diastatic  value  one  hundred  times  less 
than  that  of  saliva.  {See  the  author's  paper  on  "  The  Estimation  of  the  Amylo- 
lytic  and  Proteolytic  Activity  of  Pancreatic  Extracts."  Proc.  Roy.  Soc,  18'81.) 
Griitzner  states  that  urine  also  contains  rennet  ferment  and  peptones,  together 
with  pepsin  and  trypsin,  the  last  in  the  form  of  a  zymogen.  (Bresl.  artz.  Zeit- 
schrift.  No.  17.) 

3 


34 


INTEODUCTORY. 


may  be  judged  of  by  the  following  table,  whicli  has  been  con- 
structed from  a  large  number  of  the  best  analyses : 

Water  ■ 954.81 

Solid  matters 45.19 


Urea 
Uric  acid 


Extractives 


^  i 


Chlorine 

Sulphuric  acid 

Phosphoric  acid 

Potash    . 

Soda 

Lime 

Magnesia 


Creatine,  creatinine 
Ammonia,  hippuric  acid 
Xanthine,  hypoxanthine 
Sarcine,  pigment,  unoxidized  sulphur  and 
phosphorus,  mucus,  etc. 


21.57 
0.36 


6.53 


4.57 
1.81 
2.09 
1.40 
7.19 
0.11 
0.12 


The  composition  and  physical  properties  of  the  urine  may 
undergo  alterations  from  physiological  and  from  pathological 
causes. 

Physiological  Alterations. — The  physical  properties  of  the 
urine,  and  the  relative  proportion  of  its  ingredients,  vary  greatly 
under  the  different  conditions  of  healthy  existence.  Exercise, 
rest,  the  quantity  and  quality  of  the  food  and  drink,  digestion, 
fasting,  sleep,  the  quantity  of  the  cutaneous  transpiration,  atmos- 
pheric states,  etc.,  react  on  the  urine;  and  are,  so  to  speak, 
reflected  in  its  composition. 

Some  of  the  urinary  constituents  are  derived,  wholly  or  in 
part,  directly  from  the  food.  This  is  especially  the  case  with  the 
saline  or  mineral  matters,  and  the  water.  When  the  diet  is 
especially  rich,  or  especially  poor,  in  any  of  these,  their  relative 
proportions  in  the  urine  rise  or  fall  correspondingly. 

Again,  certain  constituents  (especially  water)  have  other  ways 
of  passing  out  of  the  body  than  the  kidneys,  namely,  by  the 
skin,  the  lungs,  the  intestines;  and  if  these  show  any  unusual 
activity,  the  composition  of  the  urine  is  necessarily  affected. 
The  greatest  constancy  of  proportion  is  exhibited  by  the  organic 
(nitrogenized)  constituents — urea  and  uric  acid,  etc. — which  are 
derived  from  the  disintegration  of  the  tissues ;  but  even  these 
oscillate  not  a  little  with  the  quantity  and  quality  of  the  food, 
and  with  exercise  or  rest  of  the  body.  The  reaction,  which 
influences  so  importantly  the  physical  properties  of  the  urine, 
and  its  capacity  for  holding  in  solution  certain  ingredients  which 
otherwise  tend  to  be  precipitated,  is  greatly  affected  by  the 
digestion  of  food,  and  may  be  changed  thereby  from  acid  to 
alkaline  during  several  hours  in  the  day. 


METHODS    OF    EXAMINING    THE    UKINE.  dO 

Pathological  Alterations  may  be  distinguished  mio  general 
and  special.  It  is  desirable  to  indicate  these  separately;  though 
practically  they  frequently  merge  into  each  other. 

General  pathological  alterations  are  those  which  depend  on 
some  general  bodily  disorder,  such  as  fever,  rapid  waste  of  the 
tissues,  anEemia,  etc.  Alterations  of  this  class,  although  of  great 
interest  for  the  elucidation  of  general  pathological  doctrines, 
have  very  little  symptomatic  value;  and  it  has  not  been  shown 
that  a  particular  knowledge  of  them  in  an  individual  case  of 
disease,  is  capable  of  furnishing  any  information  on  diagnosis, 
prognosis,  or  treatment,  which  may  not  be  obtained  more  easily 
and  accurately  by  other  means,  namely,  by  physical  examina- 
tion of  the  organs,  temperature  measurements,  weighing  the 
patient,  etc. 

Special  'pathological  changes  are  :  {a)  those  in  which  some  new 
and  unnatural  ingredient  is  mixed  with  the  urine — such  as  albu- 
men, sugar,  fat,  cystine,  blood,  pus,  fibrine,  epithelial  cells, 
spermatozoa,  etc. :  (h)  those  in  which  some  constituent  is  present 
in  such  unnatural  proportion  that  the  circumstance  forms  a  lead- 
ing feature  of  some  particular  disease — as  the  excessive  quantity 
of\vater  in  diabetes,  the  excessive  diminution  of  urea  in  Bright's 
disease,  etc.;  (c)  those  in  which  some  constituent  is  in  an  un- 
natural physical  condition — thereb}^  producing  or  indicating  a 
particular  morbid  state  —  as  in  the  occurrence  of  uric  acid, 
oxalate  of  lime,  and  earthy  phosphates  as  urinary  deposits  or 
calculous  concretions. 

In  the  present  work,  physiological  and  general  pathological 
changes  of  the  urine  are  only  considered  in  so  far  as  they  pos- 
sess some  practical  interest.  The  special  pathological  changes, 
on  the  other  hand,  are  considered  at  length. 

11.— METHODS  OF  EXAMINING  THE  URIISrE— APPAEATUS 
REQUIEED. 

An  examination  or  analysis  of  the  urine  for  clinical  purposes 
is  much  more  restricted  in  its  objects  than  one  which  is  designed 
for  original  investigations. 

The  object  of  the  former  is  to  ascertain  those  points,  a  knowl- 
edge of  which,  in  a  particular  case,  is  found  from  previous 
experience  to  throw  a  light  on  the  nature,  course,  diagnosis,  • 
prognosis,  or  treatment  of  the  disease.  The  object  of  the  latter  is 
to  obtain  new  and  additional  indications  in  the  same  directions ; 
it  embraces  every  conceivable  information,  and  is  consequently 
indefinitely  elaborate. 

The  subjoined  scheme  is  of  the  former  kind,  and  is  sufficiently 
simple  to  be  within  reach  of  every  practitioner.    It  requires-  only 


36 


INTRODUCTORY. 


an  elementary  knowledge  of  chemistry,  and  answers  nearly  all 
the  requirements  of  actual  practice. 

The  points  requiring  to  be  noted  in  an  examination  of  the 
urine  are — 

1.  The  general  appearance  and  color;  clearness  or  turbidity; 
presence  or  absence  of  deposit,  and  of  extraneous  impurities. 

2.  Odor. 

3.  Reaction. 

4.  Specific  gravity. 

5.  Presence  or  absence  of  albumen :  if  present,  an  approxi- 
mate estimate  of  its  quantity. 

6.  Presence  or  absence  of  sugar :  if  present,  an  estimate  of 
its  quantity. 

Fig.  1. 


Apparatus  for  urine-testing.     A.  Urine-glass — depth,  53^2  inches ;  diameter,  l)^  inch.  ,  B.  Urinometer. 
C.  Burette.     D.  200  grain  measure.     E.  Stand  of  urine-tests. 

7.  An  estimate  of  the  total  quantity  of  urine  in  twenty-four 
hours. 

If  there  be  a  deposit,  it  is  necessary  to  note — 

8.  Its  aggregation  and  color :  whether  it  be  amorphous  or 
crystalline,  light  or  heavy;  the  manner  of  its  subsidence  or 
precipitation. 

9.  Its  solubility  or  insolubility  by  heat;  solubility  in  nitric 
acid,  in  acetic  acid,  in  liquor  potassse;  insolubility  in  both  acids 
and  alkalies. 

10.  By  the  microscope  :  absence  or  presence  of  crystals,  their 


EXTRANEOUS    MATTERS    IX    URINE.  .'iT 

appearance  and  form;  of  epithelial  cells — renal  or  extrarenal; 
of  blood  disks;  pus  globules;  spermatozoa:  librinous  cylinders; 
bacteria,  etc. 

The  apparatus  required  consists  of — 

1.  Three  or  four  urine-glasses.     Fig.  1,  A. 

2.  Litmus  paper. 

3.  Urinometer.     B. 

4.  Ilalf-a-dozen  test-tubes. 

5.  Spirit-lamp. 

6.  I^itric  acid. 

7.  Acetic  acid. 

8.  Liquor  potassse. 

9.  Liq.  ammon.  fort. 

10.  Drop-tubes  and  stirring  rods. 
For  sugar  testing — 

11.  Prepared  copper  solution. 

12.  Graduated  burette.     C. 

13.  Two-hundred-grain  measure.     D. 

14.  Six-ounce  graduated  measure. 

15.  Small  flask. 

These  may  be  conveniently  arranged  together  for  use  on  a 
circular  stand  of  two  tiers,  as  represented  at  E,^ 

A  microscope  is,  of  course,  essentially  necessary.  It  should 
be  provided  with  a  first-class  :^-inch  object-glass,  and  an  eye- 
piece to  magnify  not  less  than  240  diameters. 

III.— EXTEANEOUS  MATTERS  IN  UEINE. 

It  is  important  that  the  student  should  be  familiar  with  the 
appearance  of  certain  extraneous  matters  which  are  apt  to  find 
their  way  into  the  urine  after  emission,  and  to  be  mistaken  for 
urinary  deposits. 

Cotton  fibres  {see  Fig.  2,  a)  have  a  flat  limp  appearance,  are  often 
folded  on  themselves,  usually  with  a  dark-looking  medullary 
part ;  sometimes  they  present  the  appearance  of  narrow  glassy 
cylinders.  They  vary  in  breadth  from  3  q\^  q  to  YTunr  ^^  ^^^  inch. 
Flax  fibres  (b)  are  jointed  at  intervals,  and  have  a  round,  solid 
appearance.  Their  broken  ends  are  usually  torn  into  a  brush  of 
fibrillse.  When  sharply  bent  they  break  with  a  "  green-stick", 
fracture,  WooUe7i  hairs  (c)  present  the  appearance  of  hard  cylin- 
ders, with  fine  transverse  markings  and  slight  serrations  along 
their  margins.     From  their  elongated  form  and  somewhat  simi- 

1  This  stand  was  constructed  for  me  by  Mr.  Payne,  of  the  firm  of  Mottorshead 
&  Co.,  Market  Place,  Manchester,  from  whom  similar  ones  may  he  obtained,  com- 
pletely furnished,  for  the  price  of  £2  2s.  With  the  stand  is  supplied  a  printed 
card,  containing  directions  for  urine  testins;. 


38 


INTEODUCTORY. 


lar  diameters  these  three  objects  are  liable  to  be  mistaken  tor 
casts  of  the  uriniferous  tubes. 

The  latter,  however,  are  distinguished  by  their  softer  aspect 
and  less  defined  outline,  and  they  are  never  fibrillated  at  their 
extremities. 

A  few  air-bubbles  [d)  are  generally  retained  beneath  the  cover- 
ing-glass of  the  microscopic  slide,  and  are  apt  to  puzzle  students. 


Fig.  2. 


Extraneous  matters  found  in  urine :  a.  Cotton  libres ;  b.  I'lax  fibres ;  c.  Hairs ;  d.  Air-bubbles ;  e. 
Oil  globules ;  /.  Wheat  starch ;  g.  Potato  starch ;  h.  Kice-starch  granules ;  Hi.  Vegetable  tissue ;  Ic. 
Muscular  fibres  :   I.  Feathers. 

If  small,  they  are  spherical;  if  large,  irregularly  flattened.  They 
are  identified  by  their  strong  refraction,  deeply  colored  thick 
borders  and  clear  centres.  Oil  globules  [e)  are  sometimes  pres- 
ent in  urine  as  a  morbid  product,  in  which  case  they  are  always 
very  minute.     More  often  they  occur  as  accidental  impurities ; 


CHANGES    IN    THE    URINE    ON    KEEPING.  89 

they  may  be  derived  from  the  use  of  uii  oiled  catheter;  from 
milk,  butter,  l)roths,  and  other  articles  of  food ;  from  oily  sul^- 
stances  previously  contained  in  the  insufficiently  cleansed  bottle 
in  which  the  urine  has  been  conveyed  for  examination.  Oil 
globules  have  a  less  strongly  marked  outline  than  air-bubbles; 
they  appear  Hatter,  and  have  generally  a  distinctly  yellowish 
tint. 

Confervoid  vegetations  or  torultc  and  various  forms  of  bacte- 
ria are  frequently  encountered  in  the  examination  of  the  urine. 
The  former  are  invariably  derived  from  an  extraneous  source. 
The  latter  (bacteria)  are  sometimes  of  extraneous  origin  and 
sometimes  are  generated  within  the  urinary  passages.  These 
will  be  more  fully  noticed  hereafter.  [See  Microorganisms  in 
the  Urine.) 

From  the  sputa  may  be  introduced  portions  of  bread,  meat, 
fresh  vegetables,  as  well  as  the  epithelial  debris  of  the  oral  cavity 
and  air-passages.  Starch  granules  find  their  way  into  the  urine 
from  certain  articles  of  food,  or  the  use  of  tooth  and  cosmetic 
powders.  Wheat  and  potato  starch  granules  are  recognized  by 
their  concentric  lines  and  hilus  {fg).  Rice  granules  are  very 
minute  cubical  bodies  (A).  If  the  granules  are  ruptured  by  the 
operations  of  cookery  (as  in  bread,  puddings,  gruel,  etc.),  they 
can  no  longer  be  identified  by  their  forms,  but  a  drop  of  iodine- 
water  insinuated  beneath  the  covering-glass  instantly  strikes  a 
deep  blue  color  with  them.  Fecal  matters  may  mingle  with  the 
urine  by  inadvertence,  or  they  may  find  their  way  into  the  blad- 
der through  a  fistulous  communication  with  the  intestines.  Their 
presence  is  recognized  by  the  food  remnants  which  they  contain. 
At  ii)  and  [k)  are  represented  vegetable  tissues  and  muscular 
fibres  which  were  detected  in  the  urine  of  a  patient  whom  I  saw 
with  Mr.  Jameson,  of  Hey  wood.  The  urine  was  not  sensibly 
fecal  to  the  smell ;  but  the  discovery  of  these  structures  in  it 
proved  decisively  the  existence  of  a  narrow  communication 
between  the  bowels  and  the  urinary  tract,  and  threw  a  strong 
light  on  an  otherwise  very  obscure  case.  Particles  of  soot  and 
sand,  and  other  matters  which  may  be  designated  as  dirt,  are 
of  frequent  occurrence.  They  are  dark  shapeless  masses  of 
various  sizes,  and  all  dissimilar.  Any  object  of  undefined 
shape,  of  which  there  are  none  similar  to  itself  in  the  field, 
may  almost  with  certainty  be  set  down  as  dirt. 

IV.— CHANGES  IIS   THE  UEIjSTE  ON  KEEPING. 

The  changes  which  take  place  in  urine  after  emission  are  a 
frequent  source  of  misapprehension.  These  changes  differ  in 
degree  and  direction  according  to  the  reaction  and  concentra- 
tion of  the  urine. 


40  INTRODUCTORY. 

A  healthy  acid  urine  generally  undergoes  the  following  series 
of  changes.  There  occurs  first  a  precipitation  of  the  amorphous 
urates,  then  of  uric  acid  and  often  of  oxalate  of  lime.  After  a 
while  confervoid  vegetations  or  torulse  make  their  appearance. 
In  the  course  of  four  or  five  days  or  longer  the  acidity  begins 
to  decline,  and  the  urine  passes  into  a  state  of  ammoniacal 
putrefaction.  It  then  becomes  opaque  from  the  development 
of  myriads  of  bacteria;  the  odor  and  reaction  of  ammonia, 
together  with  an  offensive  efiluvium  of  putrefaction,  become 
perceptible.  The  amorphous  urate  deposit  will  now  be  found 
changed  into  dark  round  masses  of  urate  of  ammonia ;  uric 
acid  crystals  give  place  to  bright  prisms  of  triple  phosphate 
and  an  abundant  sediment  of  amorphous  phosphate  of  lime 
sinks  to  the  bottom  of  the  vessel.  The  confervoid  vegetations 
cease  to  grow  with  the  change  of  reaction,  and  finally  perish  as 
the  secretion  becomes  fairly  putrid. 

Urines  of  low  density  or  of  feeble  acidity  do  not  deposit 
urates  on  standing,  and  pass  rapidly — in  a  day  or  two  or  even 
in  a  few  hours — into  a  state  of  ammoniacal  decomposition. 

Under  the  name  of  the  add  urinary  fermentation  Scherer^  de- 
scribed a  series  of  changes  in  healthy  urine  chiefly  characterized 
by  a  progressive  increase  of  its  acidity,  due  to  the  production  of 
lactic  acid  and  partly  of  acetic  acid.  He  attributed  these 
changes  to  a  fermentation  in  which  the  mucus  of  the  bladder 
acted  as  a  ferment  on  the  urinary  pigment,  transforming  it  into 
lactic  acid.  Later  researches  by  Rohmann^  have  thrown  great 
doubt  on  the  correctness  of  Scherer's  account  of  the  occurrence 
of  a  normal  acid  urinary  fermentation.  Rohmann  found  that 
in  fourteen  out  of  sixteen  specimens  of  healthy  urine  no  increase 
of  the  acidity  took  place.  In  the  remaining  two  specimens  a 
slight  increase  of  acidity  was  observed;  this  he  attributed  to 
the  presence  of  traces  of  sugar  or  of  alcohol  in  the  urine,  both 
of  them  substances  which  readily  yield  acid  (lactic  or  acetic) 
under  the  action  of  organized  ferments. 

The  changes  which  take  place  in  an  opposite  direction — that 
is,  towards  alkalescence — are  much  more  prOne  to  mislead  than 
those  just  described.  The  transformation  of  urea  into  carbonate 
of  ammonia  {see  Reaction)  is  a  frequent  source  of  confusion  in 
the  examination  of  the  urine.  This  transformation  is  brought 
about  with  great  rapidity  by  bacterial  fermentation.  The 
physical  and  chemical  characters  of  the  urine  are  then  so  altered, 
that  it  is  unfit  for  clinical  examination,  and  should  invariably  be 
rejected,  except  in  cases  where  the  transformation  takes  place 

1  Annalen  d.  Chemie  u.  Pharm.,  Bd.  42,  p.  171. 
*  Maly's  Jahresbericht  f.  Thiex-chemie,  1881,  p.  454. 


CHANGES    IN    THE    URINE    ON    KEEPING.  41 

within  the  urinary  passages  and  a  more  natural  specimen   is 
therefore  not  procurable. 

In  consequence  of  these  changes  it  is  desirable  to  examine 
the  urine  within  a  few  hours  of  the  time  of  emission.  Certain 
organic  deposits  are  liable  to  be  greatly  altered,  or  altogether 
destroyed,  by  an  exposure  of  twelve  or  twenty-four  hours,  even 
when  the  more  obvious  characters  of  the  secretion  have  not 
undergone  a  perceptible  change.  Blood  corpuscles,  renal  epi- 
thelium, andSrenal  casts,  are  very  rapidly  disintegrated,  especi- 
ally if  the  urine  be  of  low  specific  gravity.  On  the  other  hand, 
pus,  pavement  epithelium,  and  spermatozoa  resist  mucli  longer 
without  efFacement  of  their  microscopical  characters;  and  they 
may  generally  be  recognized  without  difficulty  in  urine  far  ad- 
vanced in  putrefaction. 


CHAPTER    II. 

PHYSICAL  PROPERTIES  OF  THE  URINE. 

I.— ODOE. 

The  natural  odor  of  healthy  urine  is  faint  and  peculiar;  it 
may  be  described  as  urinous;  it  is  due  to  the  presence  of  certain 
volatile  organic  acids.  The  addition  of  a  mineral  acid  greatly 
intensities,  and  to  a  certain  extent  modifies,  the  urinous  odor. 
The  sense  of  smell  is  a  rough  test  of  the  presence  of  ammonia, 
and  of  the  freshness  of  the  secretion,  or  the  advent  of  putre- 
faction. When  urine  is  alkaline  from  fixed  alkali,  it  has  a 
sweetish  aromatic  odor  like  that  of  the  fresh  urine  of  the  horse 
or  ox.  In  this  way  the  smell  of  the  urine  comes  to  be  a  ready 
index  of  its  reaction. 

Certain  drugs  (turpentine,  copaiba,  cubebs),  and  certain 
articles  of  food  (asparagus,  garlic),  communicate  peculiar  odors 
to  the  urine  which  lead  to  their  immediate  detection.  Diabetic 
urine  when  fresh  has  a  faint  whey-like  fragrance,  and  sometimes 
an  odor  resembling  chloroform  {see  Diabetic  Coma).  When  fer- 
menting, diabetic  urine  smells  like  sour  milk. 

Urine  containing  blood  or  sanious  discharges  from  the  genital 
passages  emits  a  stale,  offensive  smell,  like  the  washings  of 
slightly  tainted  flesh. 

II.— COLOK. 

The  color  of  the  urine  in  health  is  a  yellowish-brown.  It 
varies  in  intensity  from  the  palest  straw  to  a  full  amber.  The 
study  of  urinary  pigments  is  one  of  great  inherent  difficulty; 
and  it  has  been  rendered  truly  intricate  by  the  multiplication  of 
new  terms  by  successive  investigators,  and  the  confounding  of 
pigments  produced  by  decomposition  with  those  really  preexist- 
ing in  the  urine. 

The  coloring  matters  encountered  in  the  urine  may  be  divided 
into  four  categories,  viz. : 

1.  I^^ormal  pigments  of  healthy  urine. 

2.  Pathological  pigments  due  to  disease. 

3.  Derived  pigments  due  to  decomposition  of  the  normal  pig- 
ments, or  of  certain  color-yielding  extractives  of  the  urine,  espe- 
cially in  disease. 

4.  Adventitious  pigments  due  to  admixtures  of  bile,  blood, 


COLOR.  43 

hsematin,  pus,  etc.,  with  the  urine,  or  to  the  adrniiiiKtriitiori  of 
certain  drugs — logwood,  rhul)ar}),  senna,  santonin,  etc. 

1.  Normal  Pigments  of  Healthy  Ukine. — Dr.  Schunck's  in- 
vestigations^ have  led  him  to  the  conclusion  that  the  ordinary 
color  of  normal  urine  is  due  to  the  presence  of  two  substances 
having  the  properties  of  extractive  matters.  He  has  succeeded 
in  separating  these  from  one  another,  and  from  the  other  con- 
stituents of  the  urine.  They  have  then  the  appearance  of  dark 
yellow  syrups,  being  quite  amorphous  and  deliquescent,  with  a 
peculiar,  rather  pleasant  (not  urinous)  odor  and  a  strong  acid 
reaction,  which  proceeds  from  the  presence  of  organic  acids 
resulting  from  their  spontaneous  decomposition.  Tlie  dilute 
watery  solutions  of  these  extractives  have  exactly  the  same 
color  as  urine  itself. 

The  iirst  of  these  extractives — which  Dr.  Schunck  has  named 
Urian — is  soluble  in  alcohol  and  ether  as  well  as  water.  Its  com- 
position is  expressed  by  the  formula  CggHg^NOgg,  and  does  not 
vary.  In  a  long  series  of  experiments  made  with  urine  obtained 
at  diiferent  times  and  from  different  places.  Dr.  Schunck  always 
found  its  composition  the  same.  It  is  decomposed  at  a  boiling 
temperature,  yielding  a  large  quantity  of  a  brown  resin  and 
volatile  organic  acids.  Its  watery  solution  becomes  several 
degrees  darker  on  the  addition  of  sulphuric  or  hydrochloric 
acid,  and  a  brown  resinous  substance  is  gradually  deposited. 

The  second  extractive  he  has  named  TJrianine.  Its  formula 
is  C38H27NO28.  This  extractive  is  soluble  in  alcohol,  but  not  in 
ether ;  it  seems  to  have  a  great  tendency  to  absorb  four  addi- 
tional equivalents  of  oxygen  (C38II27NO32  =  oxurianine),  but 
without  suffering  anj^  change  in  its  physical  properties.  Uri- 
anine  is  probably  a  glucoside,  for  by  the  action  of  acids  it  yields 
a  brown  pow^der,  insoluble  in  water  (uromelanine),  and  the 
filtered  liquid  reduces  the  cupro-potassic  test  like  grape  sugar. 

Urian  and  urianine  are  both  decomposed  when  heated  for 
some  time  in  the  water-bath,  giving  products  which  are  in- 
soluble in  water.  Watery  solutions  of  both  become  several 
shades  darker  when  mixed  with  dilute  sulphuric  or  muriatic 
acid. 

Jaffe  has  distinguished  another  pigment  in  the  urine  to  which 
he  has  given  the  name  of  Urobilin.'^  Maly  has  shown  that  it  can 
be  formed  from  Bilirubin  by  reducing  agents,  and  that  it  is 
identical  with  Hydrobilirubin.  It  is  a  red  amorphous  substance 
and  soluble  in  alcohol,  ether,  and  chloroform,  partially  soluble 
in  water,  having  a  characteristic  spectrum,  and  giving  in  solu- 
tion a  green  fluorescence. 

1  Proceedings  Eoy.  Soc,  1867. 

2  Vircli.  Arch.,  Bd.  47.  See  also  a  paper  by  McMunn  in  Proc.  Eoy.  Soc,  1880, 
in  which  is  given  a  process  for  the  isolation  of  bilirubin. 


44  PHYSICAL    PROPERTIES    OF    THE    URINE. 

Variations  in  the  depth  of  the  normal  color  of  the  urine  cor- 
respond generally  with  its  degree  of  dilution  (or  wateriness), 
and  concentration.  Very  pale  urines  are  voided  by  patients 
suiFering  from  diabetes,  from  aneemia  and  chlorosis,  and  during 
convalescence  from  acute  diseases — also  by  healthy  persons 
after  profuse  drinking.  Hysterical  and  nervous  individuals, 
after  paroxysmal  attacks,  void  a  very  pale  urine.  As  a  rule, 
pale  urines  indicate  the  absence  of  pyrexia. 

High-colored  urines,  on  the  other  hand,  accompany  the  febrile 
state,  and  any  other  morbid  condition  associated  with  rapid 
wasting  of  the  tissues.  Healthy  persons  void  a  similar  urine 
after  violent  and  prolonged  muscular  exercise  and  severe 
sweating. 

The  varying  degrees  of  coloration  of  the  urine  have  not  as 
yet  been  made  to  yield  much  information  of  a  practical  value. 
Possibly  this  has  been  due  to  the  want  of  an  exact  method  of 
estimating  and  describing  these  variations.  A  first  step  towards 
this  desirable  object  has  been  taken  by  J.  Vogel,  who  has  pub- 
lished a  standard  scale  of  colored  plates,  with  which  the  color 
of  any  particular  urine  can  be  compared.  Vogel  divides  the 
tints  exhibited  by  urines  into  three  groups,  each  consisting  of 
three  members.  {See  Plate  I.)  The  first  group  consists  oi yellow 
urines,  embracing :  (1)  pale  yellow ;  (2)  bright  yellow ;  (3) 
yellow.  The  second  group  consists  of  reddish  urines,  and  in- 
cludes:  (4)  reddish-yellow;  (5)  yellowish-red;  (6)  red  urines. 
The  third  group  consists  of  brown  or  dark  urines.  These  are 
subdivided  into :  (7)  browmish-red ;  (8)  reddish-brown ;  and  (9) 
brownish-black. 

In  comparing  the  color  of  a  urine  with  the  tints  of  the  scale, 
the  two  following  precautions  must  be  observed,  in  order  to 
obtain  uniform  results.  If  the  urine  be  not  absolutely  clear,  it 
must  be  filtered.  Secondly,  the  urine  must  be  examined  by 
transmitted  light,  in  a  glass  which  is  four  or  five  inches  in  di- 
ameter. Lastly,  it  must  be  remembered  that  the  scale  is  not 
adapted  for  the  estimation  of  the  adventitious  pigments  some- 
times found  in  urine,  such  as  blood  or  bile ;  nor  does  it  exactly 
reproduce  some  of  the  pathological  tints  observed  in  disease.^ 

2.  Pathological  Pigments. — The  most  familiar  of  these  is  a 
reddish-pink  pigment  (purpurine  of  Bird,  and  uro-erythrine  of 
Heller),  which  makes  its  appearance  in  various  febrile  and  other 
complaints.     Purpurine  has  an  intense  affinity  for  uric  acid  and 

1  The  use  of  Vogel's  scale  for  the  purpose  of  estimating  the  quantity  of  pig- 
ment in  the  urine  is,  I  believe,  impracticable;  and  the  statement  made  by  him 
that  all  the  nine  varieties  of  color  form  one  continuous  series,  and  that  they  "  may 
be  considered  as  merely  different  degrees  of  dilution  of  one  and  the  same  pigment 
matter,"  is  certainly,  according  to  my  experiments,  inexact.  The  real  usefulness 
of  the  scale  consists  in  the  aid  it  gives  to  accurate  description. 


COLOR.  45 

the  urates,  und  when  the  latter  are  thrown  down  aH  a  deposit 
it  communicates  to  them  a  beautiful  j)iiik  color.  Purpurine 
abounds  in  the  urine  of  persons  suffering  from  severe  organic 
diseases,  and  especially  organic  diseases  of  the  liver;  it  is  like- 
wise present  in  all  febrile  and  inilammatory  urines.  It  is  said 
to  be  abundant  in  poisoning  by  lead  and  other  metals. 

A  black  pigment,  melanin,  is  excreted  in  the  urine  of  patients 
suffering  from  melanotic  tumors,  especially  when  the  disease 
attacks  the  liver  or  the  skin.  The  fact  was  pointed  out  as 
early  as  1820  by  Norris,  and  afterwards,  in  1826,  by  Faw- 
dington,  a  Manchester  surgeon.  Occasionally  the  urine  is  pale 
when  passed,  but  becomes  darker  and  deposits  a  black  or  brown 
precipitate  on  exposure  for  some  time  to  the  air,  or  immediately 
on  the  addition  of  a  strong  acid.  Thus  in  the  fresh  urine  there 
is  present  a  colorless  substance,  melanogen,  which  on  oxidation 
yields  the  dark  pigment.  Zeller^  has  lately  reported  a  very  in- 
teresting case  of  melanotic  tumors  of  various  organs,  in  which 
the  quantity  of  melanin  in  the  urine  varied,  in  inverse  propor- 
tion to  that  of  urobilin.  He  argues,  therefore,  that  the  two 
coloring  matters  must  belong  to  the  same  group  of  bodies. 

In  certain  other  conditions  the  urine  shows  the  peculiarity  of 
being  pale  when  passed,  but  becoming  dark  in  color  on  expo- 
sure to  the  air.  (See  p.  48.)  Pyrocatechin,  which  is  always 
present  in  the  urine  of  the  horse,  has  been  found  by  Ebstein 
and  Miiller  and  other  observers  in  human  urine  in  rare  cases. 
The  urine  may  then  show  the  above  reaction,  but  the  dark  color 
appears  immediately  if  caustic  alkali  is  added.  Bodecker  de- 
scribed, under  the  name  of  alkapton,  a  bodj^  in  the  urine,  which 
other  researches  seem  to  show  to  be  identical  with  Pyrocatechin. 

The  so-called  alkapton  urine  reduces  Fehling's  solution,  almost 
like  diabetic  urine,  but  differs  from  it  in  not  fermenting  with 
yeast.  In  a  case  described  by  Dr.  Armstrong  [Dublin  Journal 
of  Med.  Sci,  1882),  Dr.  Smith  found  that  the  urine,  while  pre- 
senting the  above  characters,  contained  not  pyrocatechin  but 
protocatechuic  acid, 

[A  specimen  of  urine  sent  to  me  lately  by  Dr.  Gray,  of 
Armagh,  also  contained  protocatechuic  acid.  The  patient  -was 
a  young  lady,  under  the  care  of  Dr.  Gray  and  Dr.  Whitla,  of 
Belfast,  and  had  suffered  from  symptoms  of  ulcer  of  the  stomach, 
with  apparently  perforation  and  consequent  attacks  of  localized 
peritonitis.  At  intervals  she  passed  urine  which,  while  of  ordi- 
nary color  at  the  time  of  leaving  the  bladder,  became  of  a  deep 
brown,  almost  black  color,  after  standing  for  a  short  time.  The 
urine  as  I  received  it,  that  is,  after  being  corked  up  for  some 
time,  was  of  a  pale  brown  color  and  of  an  alkaline  reaction,  and. 

1  Arch.  f.  klin.  Chirurg.,  Bd.  XXIX.  p.  245. 


46  PHYSICAL    PROPERTIES    OF    THE    URINE. 

contained  a  deposit  of  triple  and  stellar  phosphates.  There  was 
a  somewhat  more  than  normal  amount  of  indican  present.  If 
the  urine  were  exposed  to  the  air  for  a  short  time,  or  if  a  little 
liq.  potassse  were  added,  a  deep  dark  brown  color  was  produced. 
When,  however,  the  urine  was  acidified,  it  might  be  exposed  for 
some  days  without  any  alteration  in  color  occurring,  and  the 
dark  urine  became  considerably  lighter  on  the  addition  of  acetic 
acid.  The  urine  showed  only  a  slight  reducing  action  on 
Fehling's  solution,  but  immediately  reduced  an  ammoniacal 
solution  of  nitrate  of  silver.  A  weak  solution  of  ferric  chloride, 
when  added  to  the  urine,  caused  the  appearance  of  a  bluish- 
green  coloration,  which,  on  the  addition  of  a  little  liquor  am- 
monise,  changed  to  reddish-violet.  These  reactions  showed  the 
presence  of  either  pyrocatechin  or  protocatechuic  acid.  The 
peculiar  coloring  agent  was,  however,  not  distilled  over  on 
heating,  nor  removed  by  shaking  with  ether,  and  hence,  ac- 
cording to  Dr.  Smith,  it  must  consist  of  protocatechuic  acid  and 
not  pyrocatechin.  The  patient  passed  the  dark  urine  only  at 
intervals,  but  it  was  found  that  between  these  periods  the  urine 
was  acid,  and  occasionally,  at  least,  if  alkalized,  it  showed  again 
the  change  in  color.  It  is  evident  from  the  above  reactions  that 
this  dark  coloring  matter  was  a  product  of  oxidation,  but  that 
it  could  only  be  formed  in  an  alkaline  solution. — R.  M.] 

3.  Derived  Pigments. — Schunck  has  shown  that  the  normal 
pigments  of  the  urine  are  extremely  susceptible  of  decomposi- 
tion. All  strong  alkaline  or  acid  reagents,  and  even  simple 
boiling,  are  sufficient  to  change  them ;  and  there  is  little  doubt 
that  a  considerable  number  of  the  substances  described  by  pre- 
vious writers  as  pigments  preexisting  in  the  urine,  were,  either 
partly  or  wholly,  products  of  such  decompositions.  Among 
these  may  be  enumerated  the  various  brown  and  blackish  resins 
of  authors,  the  melanic  acid  of  Prout,  the  urcemaiin  of  Harley,  and 
probably  the  urochrome  of  Thudichum. 

The  discovery  of  indican  (or  a  substance  closely  resembling 
it)  as  a  normal  constituent  of  the  urine  by  Schunck,  afterwards 
confirmed  by  Carter,  has  thrown  a  strong  light  on  the  nature  of 
some  of  the  pigments  found  in  the  urine.  This  substance,  which 
appears  to  be  identical  with  the  uroxanthine  of  Heller,  imparts 
a  yellow  color  to  the  urine,  and  yields,  by  decomposition,  two 
colors  well  known  in  the  arts,  viz.,  indigo-blue  and  indigo-red  (uro- 
glaucine  and  urrhodin  of  Heller).  Indigo-blue  is  frequently 
seen  in  putrescent  urines,  forming  glistening  blue  shreds  and 
films  on  the  sides  of  the  glass  and  the  surface  of  the  urine. 
Occasionally  it  is  observed  clinically.  It  was  so  noticed  by 
Prout,  who  clearly  indicated  its  nature  and  composition.  It  is 
also  probably  identical  with  the  cyanourine  of  Braconnot.  In 
the  highly  ammoniacal  urine  of  cystitis  I  have  seen  on  two  oc- 


COLOR.  47 

casions  the  precipitated  urate  of  ammonia  tinted  of  a  beautiful 
violet  by  indigo-l)lue.  The  quantity  of  indican  in  urine  varies 
from  a  mere  trace  to  a  considerable  proportion.  For  its  detec- 
tion an  equal  part  of  hydrochloric  acid  is  mixed  Avith  the  urine, 
and  afterwards  a  concenti^ated  solution  of  chloride  of  lime  is 
added  drop  by  drop,  and  the  mixture  well  shaken.  The  in- 
dican is  then  decomposed,  forming  indigo-blue,  which  imparts 
a  greenish  or  blue  color  to  the  mixture  (Jaffe).  According  to 
Senator,  if  a  little  chloroform  or  ether  be  now  shaken  up  with 
the  solution,  this  will  take  up  the  indigo,  and  on  standing  will 
form  a  separate  layer.  The  depth  of  color  in  this  layer  will 
then  give  an  approximate  estimate  of  the  amount  of  indican 
present.  Normal  urine  treated  in  the  above  manner  is  usually 
colored  reddish-violet..  The  quantity  of  indican  in  the  urine  is 
increased  in  various  affections,  the  more  important  of  which  are 
obstructions  in  the  intestines,  peritonitis,  and  cancer  of  tVie 
stomach.  The  subject  has  been  studied,  experimentally  and 
clinically,  by  Jaffe,  who  has  found  that  obstruction  in  the  small 
intestine  and  diffuse  peritonitis  are  accompanied  by  great  in- 
crease in  the  amount  of  indican,  while  obstructions  in  the  large 
intestine  and  circumscribed  peritonitis  cause  only  a  slight  in- 
crease. Senator  has  observed  increase  of  indican  in  the  urine 
in  many  chronic  affections,  accompanied  by  changes  of  nutri- 
tion. He  has  also  found  a  similar  increase  in  cases  of  granular 
kidney,  but  not  in  other  forms  of  Bright's  Disease.-^ 

4.  Adventitious  Pigments. — In  jaundice  the  coloring  matter 
of  the  bile  is  freely  excreted  by  the  kidneys,  and  communicates 
to  the  urine  a  color  varying  from  a  saffron-yellow  to  a  dark 
olive-green.  Bile-pigment  m  urine  may  be  discovered  by 
placing  a  few  drops  of  the  secretion  on  a  white  porcelain  plate, 
with  a  few  drops  of  nitric  acid  in  juxtaposition.  The  two 
fluids  are  brought  into  contact  by  inclining  the  plate  :  if  bile  be 
present,  a  beautiful  play  of  colors — violet,  green,  and  red — is 
observed,  which  passes  rapidly  away.  Bile-pigment  appears 
in  the  urine  before  the  skin  is  perceptibly  discolored;  it  also 
continues  after  the  skin  has  attained  its  natural  tint;  so  that  its 
recognition  is  sometimes  a  useful  warning  of  impending  jaundice 
or  a  verification  of  a  preexisting  jaundice.  When  a  urine  con- 
taining bile  is  kept  for  some  days,  it  sometimes  changes  to  a 
grass-green  color  from  oxidation  of  the  biliary  pigment.- 

Dr.  Harley  considers  that  the  presence  of  the  biliary  acids  in 
the  urine  is  characteristic  of  jaundice  from  retention  of  bile,  as 
distinguished  from  jaundice  arising  from  suppression  of  bile. 

^  Salkowsky  has  described  a  great  increase  of  carbolic  acid  in  the  urine  in 
cases  of  obstruction  in  the  small  intestine.     Normal  urine  contains  only  a  trace. 

^  Marechal  has  recommended  tincture  of  iodine  as  a  test  for  bile-pigment  in 
the  urine.     It  gives  a  green  color,  passing  to  rose  and  yellow. 


48  PHYSICAL    PROPERTIES    OF    THE    URINE. 

For  the  detection  of  the  biliary  acids  he  recommends  that  a 
couple  of  drachms  of  the  urine  be  poured  into  a  test-tube  with 
a  small  fragment  of  loaf  sugar.  Then  about  half  a  drachm  of 
strong  sulphuric  acid  should  be  slowly  added,  in  such  a  manner 
that  the  two  fluids  shall  not  mix.  If  biliary  acids  be  present, 
there  will  be  observed  at  the  line  of  contact  of  the  acid  and 
urine — after  standing  a  few  minutes — a  deep  'purple  hue}  In  a 
case  of  long-standing  retention  of  bile  from  compression  of  the 
common  duct  by  a  cancerous  growth  of  the  head  of  the  pancreas, 
which  I  saw  with  Dr.  Henry  Simpson,  only  a  brandy-red  colora- 
tion of  the  urine  was  produced  by  the  application  of  this  test. 

Blood  and  pus  mixed  with  the  urine  communicate  to  it  their 
appropriate  colors.  {See  Hsematuria,  Hsemoglobinuria,  and  Pus 
in  Urine.) 

Certain  medicinal  and  poisonous  substances  administered  in- 
ternally produce  peculiar  alterations  of  color  in  the  urine. 
Creasote,  and  the  external  application  of  tar  ointment,  have 
been  known  to  produce  a  very  dark,  almost  hlack  urine.  In 
some  cases  of  this  kind  which  occurred  in  Guy's  Hospital,  Dr. 
Odling  identified  the  dark  coloring  matter  with  indigo-blue, 
and  he  pointed  out  the  close  chemical  relations  between  indigo 
and  creiisote.^  The  application  of  carbolic  acid  solutions  to  the 
surface  of  wounds  also  causes  the  urine  to  become  very  dark, 
and  occasionally,  although  the  urine  is  light  when  passed,  it 
becomes  darker  on  exposure  to  the  air.  Baumann  and  Preusse* 
have  shown  that  this  is  due  to  the  presence  in  the  urine  of  hy- 
drochinon,  a  further  oxidation  product  of  carbolic  acid.  It  is 
excreted  as  a  sulphate  which  is  colorless,  and  very  easily  de- 
composed. The  free  hydrochinon  then  absorbs  oxygen  from 
the  air,  and  forms  a  dark  pigment  which  gives  the  peculiar 
color  to  the  urine.  Marcet,  Prout,  and  Dulk  have  also  de- 
scribed cases  in  which  a  black  coloring  matter  existed  in  the 
urine.  In  patients  taking  gallic  acid  a  dusky  hue  is  communi- 
cated to  the  urine.  Yogel  records  an  instance  of  black  dis- 
coloration of  the  urine  after  poisoning  by  arseniuretted  hy- 
drogen.    (See  Hsemoglobinuria.) 

Rhubarb  given  internally  colors  the  urine  a  deep  gamboge- 
yellow,  which  is  changed  to  red  by  the  addition  of  ammonia. 
Senna  communicates  a  brownish,  and  logwood  a  reddish  tinge  to 
the  urine  when  administered  as  infusions.  Santonin  imparts  a 
conspicuous  orange-red  color  to  the  urine  if  it  be  alkaline,  and 
a  rich  golden-yellow  if  it  be  acid. 

^  Harley  on  Jaundice,  p.  61. 

2  Bird's  Urinary  Deposits,  5th  ed.,  n.  336. 

3  Zeitschrift  f.  Phys.  Chemie,  III.  p.  156. 


SPECIFIC    GRAVITY.  49 


III.— DENSITY  OR  SPECIFIC  GRAVITY. 

The  specific  gravity  of  the  urine  is  estimated  ]>y  rneaii.s  of 
the  iirinoraeter.  The  instrument  indicates  whether  the  urine 
is  concentrated  or  dilute :  and  as  the  range  of  health  is  very 
great,  the  density  does  not  yield  direct  indications  of  disease; 
nevertheless  the  information  thus  furnished  is  in  some  cases  of 
great  importance,  and  indicates  at  once  the  path  of  further 
research. 

The  usual  range  of  density  in  healthy  urine  extends  from 
1015  to  1025 ;  but  it  frequently  mounts  above  or  sinks  below 
these  limits.  After  abundant  potation  on  an  empty  stomach 
the  urine  is  profuse  in  quantity,  clear,  and  dilute  as  water. 
Under  such  circumstances  the  density  may  fall  as  low  as 
1000.6,  and  numbers  varying  from  1002  to  1008  are  common. 
Copious  drinking  on  a  full  stomach  has  comparatively  little 
immediate  efl'ect  on  the  flow  of  urine.  Prolonged  fasting  ren- 
ders the  urine  concentrated.  How  high  it  is  possible  for  the 
density  to  mount  in  healthy  individuals  it  is  diflicult  to  say;  but 
I  have  known  it  as  high  as  1036.  With  this  very  considerable 
range  in  health,  caution  must  be  exercised  in  drawing  inferences 
from  any  unusual  depression  or  elevation  of  the  density  in  dis- 
ease. If,  however,  the  urine  exhibit  habitually,  and  especially 
in  the  morning  before  breakfast  when  the  urine  is  naturally 
concentrated,  a  density  below  1015,  the  presence  of  albumen  in 
it  may  be  suspected;  if  the  density  persist  at  a  still  lower  point — 
1005  to  1008 — the  existence  of  insipid  diabetes  is  to  be  appre- 
hended. After  hysterical  paroxysms  in  women,  after  similar 
attacks  in  men,  and  sometimes  in  the  apoplectic  state,  the  urine 
is  discharged  in  large  quantity  and  of  exceedingly  low  density. 
In  cases  of  suppression  of  urine  from  mechanical  obstruction, 
the  urine — if  any  escape  past  the  obstacle — is  of  remarkably 
low  density.  This  peculiarity  will  be  treated  of  more  fully  in  a 
future  chapter.     {See  Suppression  of  Urine.) 

On  the  other  hand,  a  density  above  1025,  especially  in  a  pale, 
apparently  dilute  urine,  is  strongly  suspicious  of  the  presence  of 
sugar ;  and  the  higher  densities,  from  1035  to  1050,  belong 
almost  entirely  to  saccharine  diabetes.  Yet,  not  exclusively  so; 
the  heaviest  urine  ever  submitted  to  my  examination,  which  had 
a  density  of  1065,  did  not  contain  a  particle  of  sugar,  but  a  very 
large  quantity  of  albumen. 

A  high  density  in  a  urine  free  from  sugar  indicates  concentra- 
tion, and  more  particularly  a  large  percentage  of  urea.  In  the 
febrile  state  there  is  an  absolute  increase  of  urea,  uric  acid, 
and  the  sulphates  in  the  urine,  with  a  diminished  elimination  of 
water,  consequently  the  specific  gravit}-  ranges  high.     The  urine 

4 


50  PHYSICAL    PROPERTIES    OF    THE    URINE. 

has  also  a  high  density  when  there  is  rapid  wasting  of  the  tissues, 
especially  if  there  he  concurrent  sweating  or  diarrhoea,  in  simple 
abstinence  after  profuse  perspiration  from  any  cause,  and  after 
excessive  ingestion  of  nitrogenized  food  without  a  corresponding 
use  of  aqueous  fluids. 

From  the  density  of  the  urine,  a  rough  estimate  may  be  formed 
of  the  percentage  of  solid  constituents  contained  in  it;  and  if 
the  quantity  voided  in  twenty-four  hours  be  known,  the  daily 
excretion  of  what  may  be  called  "solid  urine"  can  be  approxi- 
mately ascertained.  Tables  have  been  constructed  on  an  experi- 
mental basis,  exhibiting  the  quantity  of  solid  matters  per  1000 
parts  in  urines  of  different  spe-cific  gravities ;  and  formulae  have 
been  proposed  by  means  of  which  the  same  result  can  be  obtained 
by  a  simple  calculation.  Probably  the  most  accurate,  as  well 
as  the  simplest  formula,  is  that  proposed  by  Trapp.  According 
to  this,  if  the  last  two  figures  of  the  specific  gravity  are  doubled, 
the  quotient  represents  the  amount  of  solid  matters  per  1000. 
A  thousand  grains  of  urine,  sp.  gr.  1020,  would  therefore  contain 
40  grains  of  solids. 

This  method  yields  but  rough  approximations.  If  the  urine 
were  a  solution  of  a  single  substance,  or  of  a  number  of  different 
substances  in  a  fixed  proportion  to  each  other,  the  rising  and 
falling  density  would  indicate  accurately  the  varying  strength  of 
the  solution ;  but  the  urine  is  a  fluid  of  complex  composition, 
and  its  numerous  constituents  vary  every  hour  in  their  mutual 
proportions,  so  that  the  results  obtained  in  this  wa}^  cannot  be 
regarded  as  exact  estimates.  Vogel  took  the  trouble  to  inquire 
what  are  the  precise  limits  of  error  in  this  method;  and  he 
assigns  them  as  follows  :  In  healthy  urines  there  is  a  liability  to 
error  of  -^o^^  even  i ;  but  in  morbid  urines,  and  especially  those 
of  high  density,  the  range  of  error  may  reach  i  or  even  ^. 
With  very  multiplied  observations  this  method  certainly  yields 
results  of  practical  value ;  and  it  is  the  only  one  which  can  be 
used  by  practitioners  generally.  When  more  accurate  results 
are  required,  resort  must  be  had  to  the  tedious  but  more  exact 
method  of  evaporation  to  dryness,  and  weighing  the  residue. 

From  a  large  number  of  observations  by  different  physiolo- 
gists. Dr.  Parkes  estimates  the  mean  discharge  of  solid  urine  in 
healthy  men,  between  twenty  and  forty  years  of  age,  living  on 
good  diet,  at  945  grains  per  day. 

IV.— QUANTITY  OF  THE  UKINE. 

Closely  connected  with  the  specific  gravity,  and  holding  an 
inverse  relation  to  it,  is  the  quantity  of  the  urine.  The  mean 
daily  discharge  ranges,  in  health,  between  40  and  50  fluid- 
ounces.     There  are,  however,  considerable  differences  between 


QUANTITY. 


51 


individuals.  The  average  for  some  persons  is  only  35  ounces 
a  day;  for  others  as  much  as  07  ounces.  Oscillations  in  the 
same  individual  on  different  days  are  also  very  considerable. 
The  urine  may  mount  to  70  or  80  ounces,  or  sink  to  25  ounces 
within  the  limits  of  health. 

The  flow  of  urine  is  essentially  regulated  by  the  quantity  of 
fluid  drunk:  controlled,  however,  in  a  most  important  degree 
by  the  pulmonary  and  cutaneous  exhalation,  and  by  the  call  of 
the  system  for  water  at  the  time.  When  the  blood  and  tissues 
contain  their  full  complement  of  water,  any  further  potation 
results  in  immediate  diuresis,  whereby  the  superabundance  is 
carried  oflf.  But  when  the  organs  and  tissues  of  the  body  are 
craving  for  more  water,  a  large  quantity  may  be  drunk  without 
causing  diuresis.  The  kidneys  eliminate  water  in  strict  accord- 
ance with  these  conditions — it  being  an  essential  and  important 
part  of  their  function  to  regulate  the  aqueousness  of  the  blood. ^ 

There  is  very  great  irregularity  in  the  flow  of  urine  from 
hour  to  hour  as  the  conditions  of  its  separation  vary.  After 
prolonged  fasting  the  urine  may  sink  to  2 J  drachms  per  hour; 
during  sleep,  likewise,  the  urine  flows  slowly — at  the  rate  of 
about  half  an  ounce  per  hour;  but  after  meals  it  rises  to  two 
or  three  ounces;  and  after  drinking  abundantly  on  an  empty 
stomach  I  have  seen  26-|  ounces  secreted  in  an  hour;  so  that 
the  stream  of  urine  may  run  85  times  stronger  at  one  time  than 
another.  It  would  seem,  indeed,  as  if  the  kidneys  (in  health) 
supplied  conditions  of  an  almost  mechanical  nature,  by  which 
they  were  enabled  to  separate  water  at  an  almost  unlimited 
rate — equal,  at  least,  to  the  capacity  of  the  gastric  vessels  to 
absorb  water. 

When  the  mode  of  life  is  equable,  and  the  meals  are  taken 
at  regular  intervals,  the  quantity  of  urine  secreted  at  different 
periods  of  the  day  and  night  follows  certain  tolerably  regular 
oscillations,  as  is  shown  in  the  following  table,  which  is  a  fair 
sample  of  a  very  large  number  of  observations  : 


Breakfast  at  8 

;  dinne 

•  a 

t2. 

SLeepfrom  11 

P.M.  to  7  A.M. 

Time  of  duy. 

7-8  A.M. 

8-9 

oz.  dr. 
1     0 

9-10 

(iz.  dr. 
2     0 

10-11            11-12 

12-2  P.M. 

Hourlj'  rate. 

oz    dr. 
0     6 

oz.  dr.           oz.  dr. 
14              17 

oz.  dr. 
1     3 

Time  of  day. 

2-3  F.Ji. 

3-i 

4-5 

5-6 

6-7 

7-9       9-11 

11-7   A.M. 

Hourly  rate. 

oz.  dr. 
1     2 

oz.  dr. 
10     0 

oz.  dr. 
2     3 

oz.  dr. 
2     8 

oz.  dr. 
2     9 

oz.  dr.  !oz.   dr. 
14      10 

OZ.  dr. 
0     4 

^  The  experiments  on  which  these  and  the  remarks  which  follow  are  based,  are 
fully  detailed  in  two  papers  by  the  author — one  in  the  memoirs  of  the  Manch. 
Lit.  and  Phil.  Soc,  1858-9;  and  the  other  in  the  Edinb.  Med.  Journ.,  March 
and  April,  1860. 


52 


PHYSICAL    PROPEKTIES    OF    THE    URINE. 


A  much  closer  insight  into  the  varying  activity  of  the  kidney 
is  obtained  by  comparing  the  quantity  of  solid  urine  excreted  at 
difierent  periods  of  the  day.  The  solid  matters  are  much  more 
constant  in  their  quantity  than  the  volume  of  the  urine,  which 
is  liable  to  be  greatly  aifected  by  potation,  perspiration,  etc. 
The  annexed  table  contains  the  average  results  of  observations 
made  during  seven  days,  all  consecutive  except  one.  The  solid 
urine  was  calculated  from  the  specific  gravity  in  the  manner  ex- 
plained in  the  preceding  section  : 


Time  of  clay. 

Solid  urine  discharged  per  hour, 
in  grains. 

Diet,  etc. 

8-   9  A.M. 
9-10     " 

10-11    " 
11-12    " 
12-  2  P.M. 

29  27 
39.22 
44.34 
45.24 
41,48 

Breakfast  at  eight;  coffee  or  tea,  with 
meat  and  bread  and  butter. 

2-  3  P.M. 

3-  4    " 

4-  5    " 

5-  6    " 

6-  7    " 

7-  9    " 
9-11    " 

11-    1  A.M. 

38.69 
38.79 
41.21 
41.09 
49.01 
47.44 
37.66 
28.53 

Dinner  at  two ;  meat,  potatoes,  bread, 
cheese,  water. 

(No  solid  food  of  any  sort  taken  after 
dinner.) 

1-   7  A.M. 

15.53 

Hours  of  sleep. 

7-   8  A.M. 

17.75 

Prolonged  fasting  in  the  waking  state. 

The  table  shows  in  an  interesting  manner  the  increase  of  the 
renal  excretion  after  meals,  and  its  diminution  during  fasting 
and  sleep.  The  increase  began  within  the  first  hour  after 
breakfast,  and  continued  during  the  succeeding  two  or  three 
hours ;  then  a  diminution  set  in,  and  continued  until  an  hour  or 
two  after  dinner.  The  effect  of  dinner  did  not  appear  until  two 
or  three  hours  after  the  meal;  and  it  reached  its  maximum 
about  the  fourth  hour.  From  this  period  the  excretion  steadily 
decreased  until  bed-time.  During  sleep  it  sank  still  lower,  and 
reached  its  minimum — being  not  more  than  one-third  of  the 
quantity  excreted  during  the  hours  of  digestion. 

All  the  urinary  ingredients  appeared  to  partake  in  the  in- 
crease after  meals.  The  urea  was  found  more  than  doubled ; 
the  uric  acid  more  than  trebled;  the  earthy  and  alkaline  phos- 
phates nearly  doubled. 

The  table  shows  that  the  vegetative  functions  share  to  some 
extent  with  the  animal  in  the  repose  of  sleep.  The  mean  hourly 
discharge  of  solid  urine  during  the  waking  hours,  on  the  seven 
days  of  the  table,  was  33.14  grains;  while  the  average  of  the 


QUANTITY.  53 

hours  of  sleep  was  15.5'j  grains,  or  less  tliari  one-half.  This 
ditference  is  not,  of  course,  to  be  wholly  attributed  to  tJie  effect 
of  sleep,  inasmuch  as,  under  the  arrangement  of  meals,  during 
this  scries  of  observations,  the  period  of  sleep  was  also  a  time 
of  fasting.  A  more  exact  estimate  of  the  effect  of  sleep  alone 
is  obtained  by  comparing  the  urine  secreted  during  the  hours  of 
sleep  with  that  secreted  during  hours  of  combined  waking  and 
fasting.  If  we  take  the  last  two  hours  before  sleeping  (from  11 
to  1),  and  the  first  hour  after  waking  (from  7  to  8),  we  shall  find 
that  the  mean  discharge  of  solid  urine  in  these  three  hours  was 
23.59  grains  per  hour,  which  is  one-third  more  than  the  average 
ot  the  sleeping  hours. 

In  drawing  practical  conclusions  concerning  any  deviation 
from  the  usual  volume  and  quantity  of  the  urine,  the  following 
points  should  be  borne  in  mind. 

When  the  urine  is  unusually  scanty,  it  should  be  ascertained, 
before  pronouncing  it  a  morbid  phenomenon,  whether  the 
patient  has  abstained  from  liquids  above  his  habit,  whether 
water  has  been  eliminated  in  excess  by  some  other  channel,  as 
the  skin  or  bowels.  The  urine  is  always  scanty  in  cirrhosis  of 
the  liver;  in  some  forms  of  Bright's  disease  through  their  entire 
course;  and  in  the  last  stage  of  all  forms;  in  any  condition  of 
the  heart  which  directly  or  indirectly  causes  passive  conges- 
tion of  the  renal  veins  whereby  the  circulation  through  the 
kidneys  is  impeded.  In  the  early  stage  of  acute  Bright's  Dis- 
ease, the  urine  is  very  scanty,  sometimes  approaching  or  reach- 
ing total  suppression.  The  same  occurs  in  the  collapse  period 
of  cholera.  Partial  or  total  suppression  also  occurs  in  the  later 
stages  of  all  organic  diseases  of  the  kidneys ;  and  when  any 
mechanical  obstacle  obstructs  the  flow  of  urine.  A  diminution 
of  the  urinary  secretion  which  at  all  approaches  suppression  is 
of  most  serious  consequence,  and  is  soon  followed  b}-  a  formid- 
able train  of  symptoms,  which  bring  life  to  a  termination  unless 
speedily  relieved.     [See  Ilrsemia.) 

The  flow  of  urine  is  abundant  when  the  surface  of  the  body  is 
cool;  also  as  a  direct  and  invariable  consequence  of  potation, 
unless  some  of  the  conditions  already  mentioned  intervene. 

In  disease,  the  urine  is  discharged  in  excessive  quantity  in 
two  special  maladies — diabetes  insipidus  and  diabetes  mellitus, 
which  w^ill  be  described  in  future  sections ;  also  in  the  middle 
stages  of  atrophic  degeneration  of  the  kidneys.  Temporary 
excess  of  urine  occurs  after  hysterical  paroxysms,  and  certain 
other  convulsive  attacks  in  males  and  females.  An  increased 
tension  in  the  arterial  system,  as  in  some  cases  of  hypertrophy 
of  the  left  ventricle,  is  associated  with  increased  secretion  of 
urine.  It  is  a  curious  circumstance,  that  in  several  organic 
diseases  of  the  kidneys  in  which  the  renal  substance  is  gradually- 


54  PHYSICAL    PROPERTIES    OF    THE    URINE. 

destroyed  (atrophic  Bright's  Disease,  cystic  degeneration,  double 
hydronephrosis),  the  volume  of  the  urine  is  sometimes  increased 
though  the  solid  matters  are  diminished.  This  appears  to  be  an 
attempt  on  the  part  of  IsTature  of  a  compensating  character,  to 
maintain,  by  excessive  transudation  of  water,  the  depurating 
function  of  the  kidneys  under  failing  anatomical  conditions. 
When  at  length  the  destruction  has  gone  so  far  that  this  kind 
of  compensation  can  no  longer  suffice,  symptoms  of  fatal  sup- 
pression of  urine  rapidly  supervene. 

v.— SUPPEESSION  OF  UEINE  (ANUKIA). 

Suspension  of  the  secretion  of  urine  arises  under  two  distinct 
classes  of  circumstances.  (1)  It  may  arise  from  organic  disease 
of  the  secreting  tissue  or  from  some  disturbance  in  the  innerva- 
tion or  vascular  supply  of  the  kidneys.  These  cases  are  not 
dependent  on  any  impediment  to  the  outflow  of  the  urine  by  its 
excretory  channels,  and  I  would  propose  to  classify  them  under 
the  designation  of  non- obstructive  suppression.  (2)  The  secretion 
of  urine  may  be  suspended  by  the  establishment  of  a  mechanical 
obstruction  in  the  ureter  or  in  the  pelvis  of  the  kidney.  In 
these  cases  the  organs  themselves  are  not  primarily  at  fault,  but 
their  function  is  arrested  by  the  blocking  up  of  their  excretory 
channels.  These  may  be  designated  as  cases  of  obstructive  sup- 
pression. 

The  two  classes  of  cases  contrast  with  each  other,  not  only 
in  their  determining  cause,  but  also,  most  markedly,  in  their 
symptoms  and  course.  ISTon-obstructive  suppression  rarely,  if 
ever,  proves  fatal  as  a  direct  consequence  of  the  suspension  of 
the  secretion  of  urine,  but  through  the  general  effect  of  the 
shock  and  collapse  which  have  produced  that  suspension.  The 
cases  usually  run  a  very  rapid  course,  ending  in  death  or  in 
recovery  in  a  few  hours  or  a  day  or  two.  Suppression  from 
obstruction  produces  its  effects  more  slowly;  if  it  result  fatally, 
the  termination  is  delayed  for  eight  or  ten  days  or  more.  In 
both  classes  of  cases  the  suppression  is  frequently  not  absolute ; 
some  small  quantity  of  urine  is  generally  voided,  and  the  char- 
acter of  this  urine  is  distinctive.  In  non-obstructive  cases  the 
urine  is  either  high-colored  and  concentrated,  or  it  contains 
albumen  and  casts,  which  plainly  indicate  disease  of  the  renal 
tissue.  In  obstructive  cases,  on  the  other  hand,  the  urine  which 
escapes  past  the  obstacle  is  pale  and  watery,  and  devoid  of 
albumen  and  casts. 

1 . — Non-obstructive  Suppression. 

There  is  comparatively  little  known  about  this  subject,  and  it 
merits  a  more  extended  study. 


SUPIVRESSION    OF    URINE,  55 

In  the  terminal  stage  of  chronic  .Briglit's  DiseaHC,  the  urine  is 
often  suppressed  for  ten  or  twenty  liours  before  death,  probably 
from  the  destructive  process  in  the  kidney  having  reached  an 
extreme  degree. 

In  the  earliest  stages  also  of  acute  Bright's  Disease,  especially 
in  the  scarlatinal  form,  the  urine  is  sometimes  sup[)ressed  for 
many  hours  or  for  a  day  or  two.  The  return  of  the  urinary  flow 
is  sometimes  sudden  and  very  copious,  more  frequently  it  is 
gradual.  A  similar  suppression  may  occur  in  scarlatinal  dropsy, 
which  is  unaccompanied  by  albuminuria.  The  following  is  a 
characteristic  example : 

A  child  of  seven  had  sickened  with  scarlet  fever  about  a  fortnight 
before  my  visit.  The  attack  was  mild  ;  and  the  patient  entered  on  con- 
valescence five  days  ago.  Two  days  ago  general  anasarca  set  in,  with 
vomiting  and  purging.  The  urine  became  scanty,  almost  to  suppression. 
When  I  saw  the  child  only  two  drachms  of  urine  had  been  voided  in 
the  previous  twenty-four  hours.  It  was  of  a  deep  saflTron  color,  and 
highly  concentrated  ;  it  contained  casts,  but  not  a  trace  of  albumen. 
The  pupils  were  strongly  contracted,  and  the  tongue  and  skin  were  dry. 
There  were  vomiting  and  purging.  Under  the  influence  of  blanket  baths, 
a  considerable  amelioration  in  the  general  symptoms  was  produced  ;  but 
in  the  two  following  days  only  three  ounces  of  a  deep  yellow  urine  were 
voided.  On  the  fourth  day  violent  vomiting  came  on  again,  and  loud 
pericardial  friction  was  heard.  Death  took  place  next  day — preceded 
by  great  restlessness,  but  without  coma  or  convulsions.  The  total  quan- 
tity of  urine  voided  in  the  last  seven  days  of  life  amounted  to  between 
six  and  seven  ounces.     No  autopsy  was  permitted. 

The  most  remarkable  examples  of  this  form  of  suppression 
occur  in  that  state  of  system  which  is  called  shock  or  collapse. 
In  the  algide  stage  of  cholera  and  yellow  fever  the  urine  is  fre- 
quently suppressed  for  twenty  or  thirty-six  hours.  The  return 
of  the  flow  is  generally  gradual;  the  first  portions  of  urine  being 
scanty,  high-colored,  and  containing  blood  and  albumen. 

All  types  of  violent  fever  and  inflammation  are  liable  to  be 
comp)licated  with  suppression  of  urine.  And  a  similar  efi^ect 
may  attend  an  overdose  of  turpentine  or  poisoning  by  the  min- 
eral acids  and  other  irritants.  liiegel  has  described  diminution 
in  the  quantity  of  urine  during  paroxysms  of  lead  colic. ^ 

Suppression  also  is  a  common  attendant  on  the  shock  an'd 
collapse  following  serious  internal  injuries,  such  as  rupture  of 
the  bowels  or  of  the  liver,  spleen,  or  uterus. 

The  kidneys  appear  peculiarly  sensitive  to  injuries  or  violence 
applied  to  the  urethra,  and  rapidly  fatal  collapse  with  suppres- 
sion of  urine  has  been  known  to  follow  slight  operations  on  the 

1  Deutsches  Arch.  f.  klin.  Med.,  Bd.  21,  pp.  175,  193. 


66  PHYSICAL    PROPERTIES    OF    THE    URINE. 

urethra,  or  even  the  passing  of  a  catheter.  I  remember  an  in- 
stance in  which  death  in  twenty  hours — with  total  suppression — 
followed  catheterism  in  an  old  case  of  stricture  where  instru- 
ments had  been  repeatedly  used  before  without  any  ill-eifects. 
The  only  post-mortem  appearance  of  consequence  was  intense 
congestion  of  the  kidneys.  Sir  H.  Thompson  mentions  a  case 
in  which  a  man  with  old-standing  narrow  stricture  died  fifty- 
four  hours  after  the  passing  of  an  instrument  which  had  been 
used  at  least  a  hundred  times  before.  ISTo  damage  whatsoever 
was  found  to  have  been  inflicted  on  the  urethra.  Rigors  and 
vomiting  commenced  about  an  hour  after  catheterization,  and  not 
another  ounce  of  urine  was  secreted  from  that  time  until  death. 
In  this  case  the  kidneys  were  found  congested  to  an  extraordi- 
nary degree,  but  no  sign  of  inflammation  existed  in  any  part 
of  the  excretory  urinary  apparatus.  Similar  consequences  have 
been  known  to  follow  Holt's  operation  for  stricture.  In  Mr. 
Fayrer's  case  rigors  and  vomiting  ushered  in  collapse,  with  total 
suppression  of  urine,  and  death  in  thirty-six  hours.^ 

Renewed  attention  has  recently  been  called  to  this  group  of 
cases  by  Sir  A.  Clark  in  a  paper  read  before  the  Medical  Society 
of  London,  entitled  "Catheter  Fever."  {See  Brit.  Med.  Journ.., 
Dec.  1883.)  A  number  of  additional  examples  were  cited  in 
the  paper,  and  in  the  course  of  the  discussion  which  followed, 
but  no  fresh  light  was  throw^n  on  their  nature  or  causation. 

The  pathology  of  these  cases  is  very  obscure.  The  imme- 
diate cause  'of  the  suppression  would  appear  to  be  intense  con- 
gestion of  the  kidneys.  Disturbance  of  the  innervation  of  the 
organs  is  probably  the  primary  cause  and  possibly,  also,  in  many 
cases,  the  direct  cause  of  the  suspension  of  the  secretion. 

Death  is  too  rapid  to  be  due  to  the  non-elimination  of  the 
urinary  excreta.  The  suppression,  in  fact,  is  only  one  among 
the  many  phenomena  of  fatal  collapse. 

In  the  way  of  treatment  there  is  nothing  equal  to  the  hot 
bath.  In  many  cases  the  relief  is  both  striking  and  prompt; 
the  flow  of  urine  being  sometimes  restored  while  the  patient  is 
actually  immersed.  The  efi'eet  may  be  kept  up  by  hot  mustard 
and  meal  poultices  to  the  loins.  Hot  gruel  enemata  are  also 
useful.  Medicines  by  the  mouth  can  rarely  be  administered  on 
account  of  the  incessant  vomiting. 

Amongst  hysterical  patients  there  is  sometimes  observed,  not 
merely  the  common  symptom  of  retention  of  urine,  but  true 
suppression  of  urine.  In  many  of  the  cases  reported  as  such, 
especially  of  old  date,  this  condition  was  undoubtedly  simulated. 
Laycock,^  however,  was  amongst,  the  first  to  point  out  that  the 

^  See  a  paper,  by  W.  M.  Banks,  on  Urethral  Fever,  in  Edin.  Med.  Journ.  for 
June,  1871. 
''■  Nervous  Diseases  of  Women. 


SUPPRESSION    OF    URINP:,  57 

suppression  may  be  real.  In  rnore  recent  times  Cliarcot'  has 
called  particular  attention  to  this  fact,  and  has  described  a  case 
in  which  no  urine  whatever  was  secreted  for  as  long  as  eleven 
days.  The  utmost  ])recautions  were  taken  to  i)revent  deception. 
The  patient  sufiercd  during  this  time  from  excessive  vomiting, 
and  the  vomited  matters  were  found  to  contain  a  quantity  of 
urea.  N^o  other  ill-effects  were  observed,  and  the  urinary  flow 
was  afterwards  spontaneously  reestablished. 

2.   Obstructive  Suppression. 

The  most  common  case  ot  obstructive  suppression  is  due  to 
the  impaction  of  a  stone  in  the  ureter  of  a  person  who  has  only 
one  kidney,  or,  at  least,  only  one  capable  of  secreting  urine. 
Sometimes  one  of  the  kidneys  is  congenitally  absent;  or  one 
kidney  has  been  permanently  disabled  at  some  preceding  period 
of  life  by  the  lodgement  of  a  stone  in  its  ureter,  or  by  some  other 
accident  or  disease.  In  such  a  case  the  passage  of  a  stone  into 
the  ureter  of  the  surviving  kidney  would,  of  necessity,  produce 
complete  suppression  of  urine.  The  next  most  common  case  is 
due  to  the  blocking  up  of  the  terminal  portions  of  the  ureters 
by  the  progress  of  a  morbid  growth,  involving  the  base  of  the 
bladder.  The  less  frequent  cases  depend  on  some  congenital 
malformation  of  the  ureters,  or  of  the  renal  arteries,  whereby 
an  impediment  is  constituted  to  the  outflow  of  urine.  This  may 
be  slight  at  first,  but  in  process  of  time  it  becomes  progressively 
greater,  until  at  length  it  arrests  the  secretion  of  urine.  Ex- 
amples of  these  three  modes  of  obstruction  will  be  found  among 
the  following  cases.^ 

A  case  of  suppression  from  obstruction  seldom  reaches  a  fatal 
climax  without  some  urine  having  been  voided  during  its  course 
— it  may  be  a  few  ounces,  or  it  may  be  a  few  pints.  The  char- 
acter of  this  urine  is  very  remarkable.  Instead  of  being  high- 
colored  and  concentrated  —  as  one  would  expect  under  such 
circumstances — it  is  pale  and  watery,  and  of  very  low  specific 

^  Diseases  of  the  Nervous  System,  New  Syd.  Society,  vol.  i. 

^  [An  unusual  cause  of  obstructive  suppression  of  urine  recently  came  under 
my  notice  in  the  Post-mortem  Theatre  of  the  Manchester  Koyal  Infirmary.  The 
right  kidney  was  transformed  into  a  large  sac  of  cheesy  matter,  and  similar 
material  filled  and  completely  blocked  the  right  ureter.  The  left  kidney  was 
enlarged,  somewhat  congested,  and  contained  numerous  small  masses  of  tuber- 
culous material,  situated  for  the  most  part  in  the  cortical  portion.  The  left  ureter 
was  slightly  distended  bj'  clear  urine  as  far  as  its  entrance  into  the  walls  of  the 
bladder.  The  bladder  itself  was  congenitally  small,  and  measured  only  IJ-  inch 
in  length.  Its  mucous  membrane  was  greatly  swollen  and  congested,  and  con- 
tained numerous  tubercular  masses.  The  orifice  of  the  left  ureter  was  surrounded 
by  thick  fibrous  tissue,  and  its  lumen  completely  closed  by  the  swollen  mucous 
membrane  of  the  bladder.  The  suppression  of  urine  had  lasted  for  five  days- 
before  death.     E.  M.] 


58  PHYSICAL    PROPERTIES    OF    THE    URINE. 

gravity.  It  may  accidentally  be  colored  by  blood,  but  it  is 
defective  in  the  proper  urinary  pigment,  and,  as  a  rule,  is  free 
from  albun,ien. 

This  peculiarity  depends  on  the  physical  conditions  under 
which  the  urine  in  these  circumstances  is  secreted.  In  order 
to  understand  the  matter  clearly,  it  v^nll  be  necessary  to  call  to 
mind  the  mutual  relations  in  health  of  the  blood  circulating  in 
the  renal  arteries  arid  the  urine  newly  secreted  from  it,  and 
flowing  down  the  nriniferous  canals.  In  the  normal  state,  the 
limiting  membrane  intervening  between  the  blood  circulating 
in  the  Malpighian  tufts  and  around  the  convoluted  tubes  on  the 
one  hand,  and  the  urine  in  the  uriniferous  canals  on  the  other, 
is  subject  on  the  side  of  the  blood  to  a  considerable  pressure, 
namely,  the  lateral  pressure  within  the  arterial  system;  while 
on  the  other  side  there  is  no  counter-pressure  at  all  so  long  as 
the  escape  of  urine  is  free. 

This  inequality  of  pressure,  as  was  first  suggested  by  Ludwig, 
and  afterwards  experimentally  proved  by  Hermann,^  is  a  capital 
factor  in  the  production  of  the  urine.  Hermann  (operating  on 
animals)  found  that  when  the  pressure  w^ithin  the  renal  artery 
was  lowered,  the  flow  of  urine  was  proportionately  diminished. 
He  tested  this  point  in  two  ways.  In  the  first  set  of  experiments 
he  lowered  the  blood-pressure  in  the  kidney  by  contracting  (by 
a  clamp)  the  calibre  of  the  renal  artery.  In  the  second  set  he 
created  a  counter-pressure  in  the  uriniferous  canals  by  impeding 
the  flow  of  urine  by  means  of  a  column  of  mercury  communi- 
cating with  the  ureter.  By  this  latter  method  he  exactly  imi- 
tated the  condition  produced  when  the  ureter  is  blocked  up  by 
a  stone,  or  some  other  mechanical  obstruction.  Hermann  found 
that  a  pressure  in  the  ureter  of  10  millimetres  of  mercury  (0.4 
inch)  caused  a  sensible  diminution  in  the  flow  of  urine ;  this 
diminution  went  on  increasing  up  to  a  pressure  of  50  millimetres; 
and  with  a  pressure  of  60  millimetres  of  mercury  (2.4  inches) 
the  secretion  of  urine  was  altogether  arrested.  In  these  experi- 
ments the  specific  gravity  and  coloration  of  the  urine  are  not 
alluded  to,  but  it  was  uniformly  found  that  the  percentage  of 
urea  progressively  diminished  as  the  pressure  in  the  ureter 
increased. 

Basing  our  deductions  on  the  clinical  facts  to  be  presently 
adduced,  and  on  the  results  obtained  experimentally  by  Her- 
mann, we  may  assume  that  a  mechanical  obstruction  in  the 
ureter  will  inevitably  produce  the  following  series  of  events : 
As  soon  as  the  obstruction  is  established  the  urine  begins  to 
accumulate  above  it;  the  accumulating  urine  determines  an 
upward  pressure  first  in  the  ureter,  then  in  the  pelvis  of  the 

1  Henle  and  Pfeufer's  "  Zeitschrift,"  1862,  p.  1. 


SUPPRESSION    OP^    UKINE.  ^}9 

kidney,  and  ultimately  in  the  ui-iiiiierouK  tuboH,  Ah  the  urino 
goes  on  accumulating,  the  pressure  within  these  channels  neces- 
sarily increases,  until  at  length  the  pressure  so  created  is  suffi- 
ciently great  in  the  uriniferous  canals  to  counterpoise  the 
pressure  within  tlie  renal  bloodvessels.  When  this  point  is 
reached  the  secretion  of  urine  is  arrested  and  total  sufipression 
ensues.^  If,  again,  the  obstruction  be  not  altogether  complete, 
and  there  be  room  for  some  urine  to  escape  past  the  obstacle, 
the  urine  so  escaping  will  have  been  secreted  under  a  high 
pressure  within  the  uriniferous  canals,  and  its  constitution  will 
be  found  thereby  materially  altered;  it  will  be  very  pale, 
watery,  devoid  of  its  proper  coloring  matter,  poor  in  urea,  and 
of  low  specific  gravity.  It  may,  indeed,  be  tinged  with  blood, 
but  this  is  an  accidental  circumstance. 

Another  point  with  regard  to  the  urine  in  obstructive  sup- 
pression is  the  irregularity  of  its  times  of  emission.  In  nearly  all 
the  cases  observed  this  is  a  marked  peculiarity.  One  day  there 
will  be  a  discharge  of  urine,  the  next  day  none,  or  perhaps  none 
for  two  or  more  days,  and  then  again  a  return  of  the  flow^,  and 
again  an  arrest.     This  point  will  be  again  adverted  to. 

The  long  delay  of  characteristic  symptoms  is  also  a  striking 
circumstance.  When  even  the  suppression  is  absolute,  seven 
or  eight  days  elapse  before  the  special  symptoms  of  ursemic 
poisoning  make  their  appearance,  but  when  these  do  appear 
the  end  approaches  rapidly,  and  death  is  not  delayed  beyond 
two  or  three  days.  Up  to  the  rise  of  the  proper  ursemic  symp- 
toms the  condition  of  the  patient  is,  as  a  rule,  Avonderfully  calm 
and  free  from  distress.  There  may  be  more  or  less  gastric  dis- 
turbance and  insomnia,  and  declension  of  the  muscular  strength, 
but  the  functions  generally  proceed  tranquilly,  and  the  intelli- 
gence is  undisturbed. 

The  most  distinctive  and  invariable  of  the  special  urtemic 
signs  are  muscular  twitchings.  I  believe  that  these  are  never 
wanting.  Contraction  of  the  pupils  is  also  a  constant  sign,  but 
later  in  its  development  than  muscular  twitches.  Eapidly  in- 
creasing muscular  weakness  is  also  constantly-  wntnessed,  and 
as  this  invades  the  respiratory  muscles  the  breathing  becomes 
markedly  slow,  panting,  and  laborious.  The  tongue  and  palate 
become  quite  dry  in  the  last  tw-o  or  three  days.  The  cerebral, 
functions   are   much   less   involved    than    might   be    expected. 

^  In  retention,  of  urine  the  obstruction  is  situated  below  the  bladder — in  the 
urethra;  and  the  physical  conditions  are  essentially  ditJ'erent  from  those  of  an 
obstruction  in  the  ureter — on  account  of  the  enormous  distensibility  of  the  bladder 
which  permits  the  urine  to  accumulate  in  that  viscus,  and  thus  prevents  the 
pressure  extending  immediately  up  the  ureters.  But  this  distensibility  is  not,  of 
course,  unlimited,  and  a  time  must  arrive — if  life  continue  and  the  obstruction 
be  not  oveicome — when  the  eft'ects  of  the  block  are  felt  in  the  ureters,  and  then 
suppression  of  urine  is  superadded  to  retention. 


60  PHYSICAL    PROPERTIES    OF    THE    URINE, 

There  is  increasing  drowsiness,  with  short,  fitful  snatches  of 
sleep-,  and  a  little  rambling  delirium,  but  absolute  coma  rarely 
supervenes,  and  convulsions  are  quite  exceptional.  The  in- 
tellect is  more  commonly  preserved  to  the  last,  and  in  more 
than  one  instance  the  patient  has  spoken  sensibly  the  instant 
before  death.  Diarrhoea  (unless  produced  artificially)  is  quite 
exceptional,  so  likewise  is  excessive  vomiting.  There  is  not 
any  dropsical  symptom.^  The  skin  is  commonly  moist,  often 
sweating  profusely.  There  is  never  any  ammoniacal  or  urinous 
odor  from  the  breath  or  skin,  nor  from  the  body  after  death. ^ 
The  power  of  taking  food  varies  :  as  a  rule,  it  is  moderate  up  to 
an  advanced  stage,  but  complete  anorexia  comes  on  a  day  or 
two  before  death. 

There  are  some  other  points  relating  to  the  morbid  anatomy, 
the  survivorship,  and  the  treatment,  which  will  be  more  con- 
veniently noticed  in  the  way  of  comment  on  the  particular  cases 
to  be  now  described,  or  in  the  concluding  part  of  the  section. 

Case  1. — A  man,  set.  67,  who  twelve  years  before  had  suffered  from 
symptoms  of  renal  colic,  but  had  not  passed  any  stone,  was  attacked 
about  six  weeks  before  his  death  with  symptoms  of  left  renal  calculus, 
with  frequent  micturition  and  pains  in  the  left  loin,  etc.  A  fortnight- 
before  his  death,  after  a  long  walk,  he  felt  a  sudden  access  of  intense 
pain  in  the  left  loin.  This  continued  in  great  severity  for  four  days,  and 
was  accompanied  with  very  frequent  and  scanty  micturition.  At  the 
end  of  these  four  days  the  urine  became  altogether  suppressed,  and  the 
pain  ceased  a  few  hours  after.  On  the  third  day  of  complete  suppres- 
sion, I  saw  the  patient.  He  had  absolutely  no  symptoms  referrible  to 
the  suspended  urinary  function ;  he  was  calm,  free  from  pain,  also  from 
nausea  and  vomiting,  without  desire  to  void  urine  ;  pulse  80 ;  tongue 
clean  ;  skin  dry  ;  he  had  had  no  sleep  for  two  nights.  He  was  ordered 
a  warm  bath,  a  saline  mixture,  and  to  have  the  course  of  the  left  ureter 
well  kneaded  with  the  aid  of  a  liniment.  Next  day  (fourth  day  of  sup- 
pression) he  passed  a  pint  of  pale,  limpid  urine;  he  had  perspired  freely 
and  slept  some  hours.  On  palpating  the  renal  regions,  the  right  was 
felt  to  be  flat  and  empty,  contrasting  with  the  left,  which  presented  its 
natural  roundness  and  sense  of  resistance. 

On  the  next  day  (fifth)  twelve  ounces  of  urine  were  voided.  It  was 
clear,  almost  colorless,  sp.  gr.  1010,  not  albuminous,  and  contained  1.92 
grain  of  urea  per  ounce.  There  were  anorexia,  thirst,  nausea,  and  occa- 
sional vomiting,  a  slight  sense  of  mental  confusion,  but  no  actual  deli- 
rium ;  pulse  80 ;  respiration  24. 

On  the  following  day  (sixth)  the  same  symptoms  continued,  with 
intense  restlessness  and  insomnia.  Sixteen  ounces  of  colorless  urine  were 
passed,  sp.  gr.  1011,  containing  2.08  grains  of  urea  per  ounce.  The  fol- 
lowing new  symptoms  also  showed  themselves — dryness  of  tongue  at  tip, 

^  For  an  exception  to  this  rule,  see  Case  10,  further  on,  and  Dr.  Eussel's  Case 
in  Med.  Times  and  Gaz.,  1879,  I.  p.  474. 
2  This  seems  a  point  of  distinction  from  rete)itio7i  of  urine. 


SUPPRESSION    OF    UKINK.  fjl 

contraction  of  pupils,  and  occasional  hiccough.  In  the  evening  of"  this 
day,  six  more  ounces  of  limpid  urine  were  voided  ;  sp.  gr.  1011 ;  tem- 
perature in  axilla  08.6°. 

On  the  afternoon  of  the  next  day  (seventh)  a  great  change  for  the 
worse  was  observed.  Pulse  80,  irregular  ;  respiration  20,  labored,  long- 
drawn,  interrupted  ;  tongue  dry  and  brown  ;  frequent  muscular  twitches 
all  over  body ;  patient  indifferent  and  drowsy,  but  answering  questions 
intelligently  ;  no  urine  for  the  last  eighteen  hours. 

Death  took  place  thirty-six  hours  after  the  last  visit — exactly  nine 
and  a  half  days  from  the  commencement  of  the  suppression.  The 
symptoms  during  this  last  period,  as  observed  by  the  late  Mr.  Mellor, 
with  whom  I  saw  the  case,  were — increased  laboriousness  and  slowness 
of  the  respiration,  which  assumed  a  panting  character;  deepening  in- 
difference, but  still  he  answered  "yes"  and  "no"  to  questions  addressed 
to  him,  though  slowly  and  unwillingly ;  pupils  contracted  to  pin's 
points  ;  finally  complete  coma.  There  was  a  doubtful  convulsive  seizure 
immediately  before  death. 

Autopsy. — Strong  rigor  mortis;  body  well  nourished,  and  quite  free 
from  urinous  or  ammoniacal  odor.  All  the  organs  healthy  except  the 
kidneys  and  ureters.  The  right  kidney  was  wholly  converted  into  a 
fibrous  mass,  studded  with  cysts,  and  weighed  two  and  a  half  ounces. 
The  corresponding  ureter  was  impervious  throughout,  and  changed  into 
a  fibrous  cord,  which  was  thickened  about  the  middle  to  double  its  width. 
This  thickened  part  was  solid  and  fibrous  like  the  rest.  No  stone  existed 
in  any  part  of  the  ureter  or  kidney,  but  it  was  conjectured  that  the 
thickened  part  of  the  ureter  had  been  the  seat  of  an  obstruction,  and 
that  the  stone,  or  whatever  object  had  constituted  the  obstruction,  had 
been  subsequently  removed  by  absorption. 

The  left  kidney  was  much  enlarged,  it  weighed  ten  ounces,  and,  on 
section,  appeared  dark  and  intensely  congested.  The  ureter  was  as 
thick  as  a  goose-quill,  and  distended  with  urine.  .At  its  lower  part  were 
found  three  little  oxalate  of  lime  calculi  about  the  size  of  hemp-seeds, 
and  weighing  altogether  a  grain  and  a  half.  One  of  these  was  tightly 
impacted  in  the  terminal  part  of  the  ureter,  where  it  passes  through 
the  coats  of  the  bladder ;  this  was  the  cause  of  the  obstruction.  The 
fluid  imprisoned  in  the  ureter  amounted  to  three  drachms,  and  consisted 
of  grumous  bloody  urine.  The  pelvis  of  the  kidney  was  only  slightly 
dilated,  and  contained  about  two  drachms  of  bloody  urine. 

The  bladder  contained  about  six  ounces  of  pale  dilute  urine  ;  its  coats 
were  healthy. 

The  course  of  events  in  this  man  appears  to  have  been  the 
following :  About  a  month  before  the  patient  came  under  ob- 
servation, three  small  calculi,  which  had  been  previous!}-  lying 
harmlessly  in  one  of  the  infundibula,  w^ere  dislodged,  and  fell 
into  the  pelvis  of  the  kidney.  Here  they  sojourned  some  four 
wrecks,  causing  pains  in  the  left  loin  and  frequent  micturition. 
At  the  end  of  this  period  they  suddenly  entered  the  ureter,  and 
for  four  days,  amid  great  suffering,  continued  their  descent  to 
its  lower  part.     Here  the  foremost  calculus  became  impacted,  ■ 


62  PHYSICAL    PROPERTIES    OP    THE    URINE. 

the  pain  ceased  suddenly,  the  passage  of  urine  was  blocked  up, 
and  suppression  ensued.  Had  the  opposite  kidney  been  intact, 
no  serious  consequences  would  have  followed.  The  healthy 
kidney  would  have  become  proportionately  hypertrophied  and 
performed  double  duty.  But  the  right  kidney  was,  by  an  unto- 
ward coincidence,  practically  non-existent.  It  had  itself,  as  may 
be  conjectured,  many  years  before  passed  through  a  train  of 
events  similar  to  that  which  had  now  extinguished  the  activity 
of  its  fellow. 

The  suppression  of  urine  in  this  case  lasted  nine  days  and  a 
half.  During  the  first  three  days  the  suppression  was  complete. 
Then  followed  a  period  of  four  days,  during  which  an  aggregate 
quantity  of  fifty-four  ounces  of  urine  was  voided.  Finally,  in 
the  last  two  and  a  half  days  no  urine  was  passed,  but  six  ounces 
were  found  in  the  bladder  after  death,  making  a  total  of  sixty 
ounces  of  urine  secreted  in  nine  days  and  a  half.  This  seems 
at  first  sight  a  not  inconsiderable  quantity,  and  causes  surprise 
that,  suppression  being  so  incomplete,  life  was  not  longer  main- 
tained. But  on  closer  inquiry  the  suppression  proves  to  have 
been  more  complete  than  at  first  appeared.  The  urine  dis- 
charged was  exceedingly  dilute,  its  sp.  gr.  ranged  from  1010  to 
1011,  and  its  proportion  of  urea  was  only  about  two  grains  per 
ounce ;  this  gives  a  total  weight  of  urea  excreted  in  nine  and  a 
half  days  of  only  120  grains,  which  is  less  than  one-fourth  of  the 
normal  amount  for  a  single  day. 

Case  2. — A  very  stout,  tall  man,  set.  59,  suffered  four  years  before 
from  symptoms  of  the  passage  of  calculi  from  the  left  kidney.  Two 
small  uric  acid  stones  were  passed  after  several  weeks  of  suffering,  and 
then  the  symptoms  subsided. 

After  four  years  of  good  health,  the  patient  was  seized  one  morning, 
without  assignable  cause,  with  sudden  pain  in  the  right  loin  and  urgent 
desire  to  pass  water.  The  pain  and  urgency  of  micturition  continued 
until  the  afternoon,  and  small  quantities  of  bloody  urine,  amounting 
altogether  to  about  half  a  pint,  were  voided  at  short  intervals  during 
the  day.  The  stomach  was  irritable  throughout  the  day.  Toward  even- 
ing the  flow  of  urine  ceased  entirely,  and  the  pain  diminished. 

I  saw  the  patient  for  the  first  time  about  fifty  hours  after  the  com- 
mencement of  the  suppression,  with  Mr.  Grindrod,  of  New  Mills;  and 
I  visited  him  daily  until  his  death,  which  took  place  nine  days  and  a 
few  hours  after  the  arrest  of  the  urinary  flow.  During  this  period  he 
only  voided  urine  once,  namely,  two  ounces  on  the  fourth  day,  and  none 
was  found  in  the  bladder  after  death.  This  specimen  of  urine  was  quite 
characteristic  of  obstructive  suppression.  Its  sp.  gr.  was  1010  ;  it  con- 
tained a  little  blood,  and  a  slight  corresponding  trace  of  albumen. 
When  the  blood-corpuscles  had  subsided,  the  urine  had  a  pale  straw 
color,  and  the  deposit  contained,  besides  blood-disks,  a  large  number  of 
epithelial  cells  of  a  transitional  character,  resembling  those  of  the  pelvis 
of  the  kidnev. 


SUPPRESSION    OP    UlilNE.  63 

The  case,  which  was  closely  watched  throughout  its  course,  presented 
a  typical  example  of  death  from  pure  anuria.  Dr.  Garrod  was  tele- 
graphed for  from  London,  and  joined  our  consultation  on  the  fifth  day 
of  suppression. 

For  the  first  six  days  the  symptoms  were  marvellously  slight,  and 
yielded  but  faint  indications  that  one  of  the  capital  functions  of  the 
body  was  in  absolute  abeyance.  The  muscular  strength  had  indeed  de- 
clined, and  the  sleep  was  bad,  but  the  patient  was  calm  ;  his  tongue,  skin, 
and  pupils  were  natural ;  there  was  little  nausea,  and  no  vomiting  after 
the  fourth  day ;  the  intellect  was  unclouded  ;  there  was  not  the  least 
urinous  or  ammoniacal  odor  about  the  breath  or  sweat;  the  pulse  was 
steady,  at  about  72,  the  respirations  24,  and  the  temperature  scarcely 
varied  from  the  normal  limits.  There  was  no  desire  to  make  water, 
scarcely  any  pain  or  tenderness  in  the  right  loin,  and  he  continued  to 
take  a  fair  amount  of  nourishment.  On  the  seventh  day  the  character- 
istic symptoms  of  suppression  began  to  show  themselves.  On  this  day 
occasional  slight  twitchings  or  pluckings  of  the  muscles  were  observed 
on  the  trunk  and  limbs,  and  the  tongue  began  to  be  dry.  The  insomnia, 
which  had  been  a  marked  symptom  from  the  first,  became  very  distres- 
sing ;  he  dozed  frequently  for  short  periods,  and  started  on  falling  asleep 
and  awaking.  He  took  nourishment  fairly,  and  had  no  vomiting  or 
thirst,  and  only  very  slight  and  transient  nausea. 

On  the  eighth  day  the  patient  was  still  calm,  and  quite  free  from 
mental  confusion  or  indifference  when  fairly  awake,  but  when  left  alone 
he  was  constantly  falling  off  in  a  fitful  doze,  and  awaking  with  a  start. 
The  muscular  twitchings  were  more  marked  than  yesterday,  and  the 
muscular  weakness  had  increased  greatly ;  nevertheless,  he  was  up  and 
dressed  in  his  bedroom  for  an  hour  and  a  half.  The  pupils  were  natural, 
and  he  took  his  food  pretty  well — a  quart  of  milk,  some  cocoa,  bread 
and  butter,  and  rice  pudding.  The  skin  had  acted  profusely  from  the 
beginning  in  response  to  warm  baths.  No  nausea  or  vomiting.  A  pecu- 
liar panting  character  of  the  respiration  was  noticed  to-day,  which 
became  more  and  more  pronounced  until  his  death.  The  temperature 
also  began  to  fall. 

On  the  ninth  day  the  patient's  condition  changed  greatly  for  the  worse. 
The  insomnia  and  restlessness  were  most  distressing ;  the  twitchings  of 
the  muscles  very  frequent  and  severe ;  the  tongue  and  mouth  were  per- 
fectly dry ;  the  pupils  were  decidedly  contracted,  though  still  sluggishly 
responsive  to  light ;  thirst  was  troublesome,  and  the  appetite  quite  gone  ; 
the  weakness  was  so  great  that  he  could  not  walk  without  the  help  of 
two  assistants ;  his  legs  had  to  be  lifted  into  the  bath.  There  was  no 
persistent  nausea,  but  he  vomited  after  a  compound  jalap  jDowder. 
Although  his  intellect  was  clear  when  he  was  roused  (he  transacted- 
some  business  with  his  lawyer"),  there  was  marked  indifference  when  he 
was  left  undisturbed,  and  he  lapsed  at  once  into  a  dozy  state,  lying  with 
his  mouth  open  and  jaw  half  dropped,  breathing  pantingly  with  long 
pause  between  expiration  and  inspiration. 

On  the  tenth  day,  at  1  p.m.,  the  patient  died,  having  lived  for  a 
little  more  than  nine  whole  days  from  the  onset  of  the  suppression,  and 
having  voided  in  this  interval  only  two  ounces  of  a  very  dilute  urine. 

The  incidents  of  the  closing  scene  were  very  distressing.     The  weak- 


64  PHYSICAL    PROPERTIES    OF    THE    URINE. 

ness  increased  rapidly ;  the  night  was  most  restless ;  the  patient  was  con- 
stantly getting  up  to  have  a  stool,  but  voided  nothing  except  a  little 
mucus;  The  thirst,  dryness  of  the  mouth,  and  the  muscular  twitchings 
went  on  increasing.  At  6  a.m.  the  breathing  became  very  embarrassed, 
threatening  suffocation.  He  asked  to  be  instantly  raised  on  the  side  of 
the  bed  into  a  sitting  posture.  He  then  belched  up  a  large  quantity  of 
flatus,  and  was  thereby  much  relieved  in  his  breathing.  After  a  couple 
of  hours  he  lay  down  agaip,  but  with  his  head  raised.  The  power  of  his 
legs  was  now  quite  gone;  he  said  he  could- not  feel  them.  At  nine 
o'clock  the  pulse  was  80,  respirations  15,  very  labored  and  interrupted. 
The  pupils  were  strongly  contracted.  The  twitchings  were  incessant  all 
over  the  body  and  limbs.  The  breathing  becoming  again  more  embar- 
rassed, he  was  lifted  on  the  side  of  the  bed,  and  finally  into  his  arm- 
chair. His  strength  failed  now  more  and  more,  and  the  breathing 
became  more  and  more  difficult,  and  the  uneasiness  and  distress  in- 
creased, dozing  and  starting  incessantly.  He  remained  in  his  chair  until 
one  o'clock,  when  he  began  to  slide  off,  and,  while  about  to  be  assisted 
up  again,  he  asked  to  have  his  hands  rubbed,  and  suddenly  fell  back 
dead.  There  was  neither  coma  nor  convulsions  throughout.  He  ap- 
peared to  wander  at  times  through  the  night,  but  when  his  attention  was 
roused,  he  showed  unshaken  consciousness  and  intelligence  to  the  end. 
The  character  of  his  breathing  in  the  last  few  days  was  peculiar,  and 
became  increasingly  so  as  death  approached.  The  inspiration  became 
more  and  more  prolonged  and  laborious,  and  expiration  shorter  and 
more  panting,  with  a  lengthening  pause  between.  The  respiratory  diffi- 
culty, which  appeared  to  be  the  immediate  cause  of  death,  evidently 
arose  from  the  diminishing  power  of  the  inspiratory  muscles. 

The  post-mortem  examination  was  confined  to  the  abdomen.  All  the 
organs  were  healthy,  except  the  kidneys  and  ureters.  The  right  kidney 
was  enlarged,  and  weighed  11*  ounces.  Its  surface  was  dotted  here  and 
there  with  numerous  black  blood-spots ;  but  the  general  appearance,, 
both  on  the  surface  and  on  section,  was  pale  mottled,  decidedly  anaemic- 
looking.  It  contrasted  strongly  with  the  dark,  almost  black  congested 
kidney  found  in  Case  1.  The  pelvis  and  ureter  were  not  in  the  least 
dilated.  They  contained  about  two  teaspoonfuls  of  blood-stained  urine. 
A  small  uric  acid  calculus  was  found  tightly  impacted  in  the  lower  part 
of  the  ureter,  just  above  its  entrance  into  the  bladder.  It  was  about 
the  size  and  shape  of  a  hemp-seed,  and  weighed  Ih  grain. 

The  left  kidney  was  found  completely  destroyed.  It  was  hollowed 
out  into  a  lobulated  sac,  about  as  large  as  the  healthy  kidney.  On  cut- 
ting it  open,  there  escaped  about  five  ounces  of  an  opaque  white  fluid, 
exactly  resembling  new  milk.  This  singular-looking  fluid  retained  its 
milky  appearance,  even  on  long  standing ;  it  was  found  to  consist  of 
myriads  of  needles  of  urate  of  soda  floating  in  a  highly  albuminous 
serum.  The  sac  wall  consisted  of  a  tough  leathery  tissue,  from  one  ta 
two  lines  in  thickness,  quite  devoid  of  any  recognizable  renal  structure. 
The  cause  of  this  mischief  was  found  at  the  entrance  into  the  ureter, 
Avhere  the  channel  was  completely  blocked  up  by  a  uric  acid  stone, 
weighing  52  grains.     The  rest  of  the  ureter  was  pervious  and  normal. 

The  bladder  was  empty  and  healthy.  The  body  generally  was  per- 
fectly sweet  and  free  from  any  urinous  or  ammoniacal  odor. 


SUI'TRESSION    OF    URINE.  65 

The  pathological  story  of  this  man's  case  was  easily  read  even 
during  life,  and  only  a  few  details  were  left  to  be  filled  in  at  the 
autopsy.  The  left  kidney  was  destroyed  four  years  before  by 
the  impaction  of  a  calculus  in  its  ureter.  The  right  kidney  then 
became  hypertrophied,  and  performed  double  duty  in  a  perfect 
manner  until  another  calculus  blocked  up  the  right  ureter. 
Then  the  secretion  of  urine  was  suddenly  and  permanently  ar- 
rested, and  the  patient  destroyed  in  less  than  ten  days. 

In  reviewing  the  symptoms  in  this  case,  it  may  be  observed 
that  insomnia  and  progressive  failure  of  the  muscular  strength 
marked  the  entire  course  of  the  case.  A  certain  disturbance 
of  the  stomach  and  slight  febrile  movement  set  in  when  the 
stone  was  impacted  in  the  ureter;  but  these  passed  away  after 
the  fourth  day.  A  fair  amount  of  nourishment  was  taken  up 
to  the  eighth  day,  after  which  the  power  of  taking  food  almost 
wholly  failed.  The  movements  of  the  pulse,  respiration,  and 
temperature  may  be  seen  by  a  glance  at  the  following  table : 

Pulse.         Respiration.      Temperature. 
Third  day      .         . 
Fourth  day  .... 


72 

— 



72 

24 

100.0° 

72 

24 

99.7 

72 

24 

99.7 

76 

20 

98.6 

76 

22 

98.2 

76 

20 

97.4 

80 

15 

— 

Fifth  day 
Sixth  day 
Seventh  day 
Eighth  day 
Ninth  dajr 
Tenth  day 

The  pulse  remained  almost  stationary,  but  with  a  slight  ten- 
dency to  increased  frequency.  The  respiration  showed  a  ten- 
dency to  diminished  frequency,  especially  toward  the  last.  The 
temperature  manifested  a  steady  tendency  to  diminution,  espe- 
cially as  death  approached.  This,  I  believe,  will  be  found  to  be 
the  general  rule  in  fatal  anuria.  Muscular  twitches  were  first 
noticed  on  the  seventh  day.  At  first  they  were  slight  and  in- 
frequent, but  they  became  more  and  more  frequent  and  severe 
as  the  case  approached  its  termination.  The  faculties  were  clear 
to  the  last  gasp ;  there  existed,  however,  in  the  last  three  days 
a  constant  tendency  to  lapse  into  indifference,  with  fitful  dozing 
and  starting,  when  the  patient  was  left  undisturbed.  The  pupils 
did  not  show  decided  contraction  until  the  ninth  day,  and  dry- . 
ness  of  the  tongue  and  mouth  became  a  marked  feature  on  the 
same  day. 

This  case  and  Case  1  illustrate  a  noteworthy  point  in  the 
morbid  anatomy  of  obstructive  suppression.  In  both  of  them 
it  is  noted  that  the  ureter  above  the  obstruction,  and  the  pelvis 
of  the  kidney,  although  moderately  filled  with  stagnant  urine, 
were  not  materially  dilated  or  enlarged.  Those  examples  of 
monstrously  enlarged  ureter  and  pelvis  (sacculated  kidney  or 


66  PHYSICAL    PROPERTIES    OF    THE    URINE. 

hydronephrosis),  which  are  often  witnessed  as  the  effects  of 
obstruction  in  the  ureter,  are  produced  by  slow  degrees,  and 
must  be  r^egarded  as  a  growth  rather  than  a  simple  dilatation. 
Indeed,  the  ureter  and  renal  pelvis  appear  incapable  of  that 
rapid  dilatation  which  we  are  familiar  with  in  the  bladder. 
This  consideration  enables  us  to  explain  how  two  different 
results  may  follow  one  and  the  same  cause,  namely,  obstruction 
in  the  ureter.  When  the  obstruction  is  suddenly  established 
and  is  at  once  complete,  the  consequence  is  not  enlargement 
and  sacculation,  but  atrophy  of  the  kidney  and  ureter.  When, 
on  the  other  hand,  it  is  slowly  established  and  is  incomplete,  it 
produces  hypertrophic  dilatation  of  the  ureter  and  pelvis,  and 
eventually  sacculation  of  the  kidney  or  hydronephrosis. 

Case  3. — A  man,  set.  40,  had  suffered  three  months  before  from  symp- 
toms of  renal  colic  on  the  right  side,  and  voided  some  small  calculi.  He 
soon  recovered  from  this  attack,  and  went  about  his  business  in  his  usual 
health,  until  three  weeks  before  his  death.  He  then  began  to  suffer  from 
pain  in  his  left  loin,  which  continued  for  a  fortnight.  During  this 
period  the  urine  was  voided  in  apparently  the  usual  quantity,  but  his 
wife  noted  that  it  had  entirely  changed  its  character.  Before  it  had 
been  high-colored,  but  now  it  became  "  clear  as  water."  At  the  end  of 
the  fortnight  complete  suppression  of  urine  came  on,  and  death  ensued 
in  five  days. 

I  only  saw  this  man  once,  on  the  day  before  his  death,  in  consultation 
with  Mr.  Edwards,  of  this  town.  He  was  then  in  a  state  of  full  uraemic 
intoxication — pupils  contracted  to  pins'  points — muscular  twitchings 
universal  over  the  whole  body — breathing  panting,  slow,  and  inter- 
rupted— tongue  and  mouth  quite  dry.  He  was  very  restless,  and  almost 
indifferent,  yet  he  answered  questions  sensibly  when  roused.  He  died 
next  day  without  coma  or  convulsions ;  he  spoke  sensibly  half  an  hour 
before  his  death. 

Autopsy  next  day.  The  body  was  quite  free  from  urinous  or  ammo- 
niacal  odor,  and  healthy  in  every  part  except  the  urinary  organs. 

The  right  kidney,  which  was  about  the  normal  size,  was  hollowed,  and 
in  process  of  atrophy ;  the  cortical  substance  alone  partially  remained, 
and  this  was  pale  and  wasted.  The  infundibula  were  moderately  dis- 
tended, and  contained  about  an  ounce  of  pale  fluid,  which  was  lost. 
The  right  ureter  was  plugged  up  at  its  commencement  by  an  elongated 
uric  acid  stone,  weighing  twenty-two  and  a  half  grains.  Another  little 
stone,  as  big  as  a  hemp-seed,  lay  in  one  of  the  infundibula.  The  ureter 
below  the  plug  was  normal. 

The  left  kidney  was  much  enlarged,  but  healthy.  It  had  the  mottled 
appearance  of  the  right  kidney  in  Case  2.  Three  little  uric  acid  calculi, 
like  flattened  mustard  seeds,  lay  free  in  the  infundibula.  The  ureter 
and  pelvis  were  moderately  distended  with  fluid  ;  the  ureter  appearing 
about  the  size  of  a  crow-quill.  On  slitting  it  open,  superficial  abrasions 
were  seen  along  its  entire  track,  showing  the  footsteps  of  a  descending 
calculus.  Near  the  bladder  this  calculus  was  found,  at  the  termination 
of  the  ureter.     It  slipped  into  the  bladder  during  the  manipulations.    It 


SUPPRESSION    OF    URINE.  67 

was  a  round  uric  acid  stone  as  large  as  a  small  pea,  and  weighed  a 
grain  and  a  half. 

The  bladder  was  empty  and  healthy. 

Though  this  case  was  seen  but  once,  the  diagnosiH  presented 
no  dithculties.  The  course  of  events  was  evidently  as  follows : 
Three  months  before  the  fatal  attack  the  right  ureter  was 
plugged  by  a  calculus,  the  function  of  the  right  kidney  was 
thereby  permanently  extinguished,  and  the  organ  at  once  passed 
on  to  a  state  of  atrophy,  which  was  nearly  complete  at  the  time 
of  death.  The  left  kidney  then  took  up  the  double  duty, 
and  became  proportionately  hypertrophied.  The  calculous  ten- 
dency, however,  was  not  arrested,  and  about  three  weeks  before 
death  a  small  calculus  passed  into  the  left  ureter.  It  con- 
tinued to  descend  amid  much  suffering,  for  about  a  fortnight, 
causing  partial  suppression  of  urii]fe.  The  urine  voided  during 
this  period  had  the  special  characteristic  of  urine  secreted  under 
pressure  from  below — i.  e.,  it  was  pale  and  watery.  At  the  end 
of  the  fortnight  the  calculus  had  reached  the  terminal  portion 
of  the  ureter;  there  it  became  immovably  impacted,  complete 
suppression  ensued,  and  death  followed  in  five  days.  It  must 
be  assumed  m  this  case  that  during  the  fortnight  of  partial 
suppression  a  certain  degree  of  blood-poisoning  took  place  from 
the  accumulation  in  the  blood  of  the  eifete  ingredients  which 
should  have  been  removed  by  the  kidneys,  so  that  when  the 
suppression  became  complete  it  only  required  five  days  (instead 
of  nine  or  ten)  to  render  the  blood  poisoned  to  such  a  degree  as 
to  be  incompatible  w4th  the  maintenance  of  life. 

Case  4. — A  man,  set.  65,  had  been  subject  for  some  years  to  attacks 
of  renal  colic,  and  had  from  time  to  time  voided  uric  acid  calculi.  Some 
fourteen  days  before  my  visit,  symptoms  of  left  renal  colic  had  set  in, 
with  pain  in  the  loin  and  frequent  micturition.  I  Avas  informed  that 
during  these  fourteen  days  a  considerable  quantity  of  pale,  clear  urine 
had  been  voided,  averaging  altogether  about  two  pints  a  day,  but  dis- 
charged irregularly.  On  some  days  none  had  been  discharged,  while  on 
other  days  it  had  flowed  copiously  at  two  or  three  separate  micturitions. 

AVhen  I  saw  the  patient  he  was  in  the  last  phase  of  uraemia  ;  the 
pupils  were  strongly  contracted;   there  were  frequent   and    universal 
muscular  twitchings :  pulse  100;  respirations  16,  markedly  panting,  but  • 
consciousness  was  intact  when  the  attention  was  roused. 

The  hypogastrium  being  protuberant  and  dull,  a  catheter  was  intro- 
duced, and  two  pints  of  urine  were  withdrawn.  This  presented  the 
usual  characteristics  of  obstructive  suppression,  it  was  very  pale,  and  its 
sp.  gr.  1006. 

Death  took  place  on  the  fifteenth  day  of  suppression,  which,  however, 
had  only  been  partial  throughout.  A  post-mortem  examination  was  not 
permitted,  but  it  was  not  difficult  to  divine  what  had  occurred.  The 
right  kidney  had  doubtless  been  destroyed  at  some  previous  period  by 


68  PHYSICAL    PROPERTIES    OF    THE    URINE. 

the  impaction  of  a  calculus  in  its  ureter.  The  left  kidney,  which  had 
then  become  the  sole  organ  of  the  urinary  function,  was  in  its  turn  sub- 
jected to  a  similar  accident;  a  calculus  entered  its  ureter  and  failed  to 
clear  the  passage  into  the  bladder,  incomplete  suppression  ensued,  and 
death  in  fifteen  days. 

This  case  is  instructive  in  one  respect,  and  suggestive  of  a 
caution  in  judging  of  the  amount  of  urinary  secretion.  This 
man  voided  on  an  average  about  two  pints  of  urine  daily. 
Had  this  amount  been  of  normal  density  and  appearance,  it 
would  have  indicated  a  degree  of  renal  activity  certainly  equal 
to  the  prevention  of  ursemic  poisoning.  Patients  may  live  for 
months  without  voiding  more  than  lifteen  or  twenty  ounces  of 
urine  a  day,  as  is  frequently  witnessed  in  cases  of  cirrhosis  of 
the  liver  and  in  regurgitant  heart  disease.  But  in  these  cases 
the  urine  is  always  of  high,  density,  deeply  colored,  and  fully 
charged  with  urinary  ingredients.  Here,  on  the  contrary,  the 
urine  was  pale  and  dilute,  and  the  density  of  the  specimen 
examined  was  only  1006.  What  amount  of  normal  urine  this 
represented  cannot  be  accurately  determined,  but  judging  by 
the  result  of  my  analysis  of  the  urine  passed  under  similar  cir- 
cumstances in  Case  1,  the  urea  would  not  amount  to  more  than 
about  one  grain  to  the  ounce.  Calculating  on  this  basis,  this 
man  excreted  only  forty  grains  of  urea  per  da}^,  which  is  not 
more  than  one-tenth  of  the  normal  amount.  Another  point  in 
the  case  deserves  notice  as  being  more  or  less  constantly  charac- 
teristic of  the  mode  of  emission  of  urine  in  obstructive  suppres- 
sion ;  this  was  the  irregularity  of  the  times  of  discharge. 
Although  the  patient  in  this  case  discharged  an  average  quantity 
of  two  pints  a  day,  this  was  not  voided  with  that  approach 
to  regularity  which  marks  the  normal  .state,  but  most  irregu- 
larly; one  day  no  urine  at  all  would  be  voided,  the  next  day  it 
would  be  voided  copiously  two  or  three  times,  then  again  none 
at  all  for  two  or  three  days,  and  so  forth.  I  have  noticed  this 
paroxysmal  character  of  the  urine-discharge  in  all  my  cases 
of  obstructive  suppression,  and  I  believe  it  to  be  a  point  of  con- 
siderable diagnostic  value. 

The  two  following  remarkable  cases  show  that  recovery  is 
possible  even  after  very  protracted  suppression  of  urine,  pro- 
vided the  flow  of  urine  can  be  reestablished.  The  notes  of  the 
two  cases  were  furnished  to  me  by  Dr.  Cliftbrd  Allbutt,  of 
Leeds,  and  Dr.  Duigan,  of  Gainsborough,  respectively.  In  the 
first  case  the  suppression  continued  for  nearly  ten  days,  and  in 
the  second  for  nine  days.  In  neither  case  were  twitchings  of  the 
muscles  noted,  but  the  pupils  had  become  contracted  in  Dr. 
Allbutt's  case,  and  there  was  some  mental  confusion.  From  my 
own  experience  I  should  regard  muscular  twitchings  as  the  first 


SUPPRESSION    OF    URINK.  69 

really  undoubted  and  characteristic  symptom  of  urtemic  [joison- 
ing;  it  cannot,  therefore,  be  said  that  recovery  followed  in  either 
case  after  the  full  declaration  of  ursemic  symptoms.  Another 
appai'ently  well-authenticated  case  of  recovery  after  nearly  ten 
days'  total  suppression,  of  obscure  nature,  is  record(id  in  the 
tenth  volume  of  the  Edinburgh  Medical  and  Surgical  Journal, 
p.  409. 

Case  5.  (From  the  notes  of  Dr.  AUbutt.) — Mr.  W.,  a  healthy  vigor- 
ous man  of  about  56,  was  first  seen  by  Mr.  Wheelhouse,  on  Wednesday, 
September  11,  1867.  He  complained  of  great  lumbar  pain,  weight, 
sense  of  fulness,  sickness,  and  febrile  disturbance. 

Monday,  16th. — Symptoms  of  descent  of  calculus  along  ureter  com- 
menced. 

Saturday,  21st. — During  this  time  stone  apparently  traced  along 
u  reter. 

October  2d. — ^Stone  from  last  date  till  now  seemed  to  be  impacted  at 
entrance  into  bladder,  constant  pain  augmented  in  paroxysms  till  3  a.m. 
this  morning,  when  sudden  and  entire  relief  was  felt,  and  the  patient 
was  told  how  to  look  for  symptoms  of  stone  in  the  bladder.  At  6  a.m. 
he  passed  the  last  quantity  of  urine,  about  5ij.  Up  to  this  time  the  flow 
had  been  free  and  the  fluid  normal. 

3d,  9  A.M. — No  urine  passed.  Catheter  used,  but  no  obstruction 
found.  Bladder  quite  empty.  3  p.m. — Same  state.  Perfect  freedom 
from  pain,  no  urine.  No  symptoms  of  ursemia.  10  p.m. — Consultation 
with  Dr.  AUbutt.  Same  state.  Temperature  100°.  Hot  bath  and 
fomentations  ordered. 

4th  (Friday),  9.30  a.m. — Same  state.  No  urine.  No  uraemia.  Much 
local  uneasiness  and  restlessness.  Temperature  98.2°.  Fomentations, 
saline  purgatives  and  diluents.  Bromide  of  potassium  with  a  little 
iodide  given  as  a  sedative,  opium  being  inappropriate.  9  p.m. — Same 
state.  A  drop  or  two  of  urine  had  been  coaxed  out,  just  enough  to  make 
a  stain  at  the  bottom  of  a  small  vessel.  No  symptoms  of  poisoning. 
Patient  quite  clear  and  much  more  comfortable. 

5th.— Mr.  W.  summoned  at  5  a.m.  Much  pain  at  the  old  point; 
cramped  limb  of  same  side;  not  a  drop  of  urine,  though  frequent  solici- 
tations; firm  pressure  on  part  gives  relief.  Sp.  ^th.  sulph.  ordered 
every  half  hour.  8.30. — Seen  with  Dr.  AUbutt.  Pain  subsided  after 
a  few  doses  of  ether;  no  urine;  breath  sweet;  perspiration  normal. 
On  examination  whole  left  side  of  belly  from  middle  line  dull ;  left 
rectus  tense;  dulness  varies  a  little  with  position.  Patient  clear  and 
intelligent;  no  drowsiness.  Ether  and  bromide  omitted.  3.  p.m. — " 
Same  condition;  pain  returning;  no  urine;  no  uraemia.  9.30. — Seen 
with  Dr.  AUbutt.  Physical  examination  :  Dulness  over  whole  of  hypo- 
gastrium  below  a  cross  line  drawn  through  the  navel;  dulness  little 
affected  by  position.  Examination  per  rectum  showed  only  a  tender 
spot  behind  the  prostate ;  no  bulging ;  catheter  passes  freely,  and  is 
moistened  with  a  few  drops  of  urine,  perhaps  twenty  or  thirty  drops ; 
upon  the  end  of  it  is  a  little  bloody  mucus.     Breath  decidedly  urinous; 


70  PHYSICAL    PROPERTIES    OF    THE    URINE. 

mind  clear ;  no  headache.  Pulse  weaker  and  quickening  a  little.  Pulse 
and  temperature  have  been  normal. 

6th,  9.30. — Pulse  96,  better ;  temperature  98.2°.  Had  passed  a  fair 
night ;  no  urine.  Dulness  of  belly  extends  a  little  above  navel  on  left 
side,  but  not  extending  so  far  to  the  right  as  yesterday.  Breath  not 
urinous.  Bowels  have  been  kept  open  by  salts  until  to-day,  when  no 
motion  was  reported.  9.30  p.m. — Singularly  clear  in  head  ;  placid  sleep 
for  five  hours.  Two  watery  stools.  No  urine,  unless  it  be  a  very  few 
drops  passed  after  repeated  efforts ;  is  cheerful,  and  walks  about  the  room 
easily,  and  is  well  able  to  sit  down  and  rise.  A  little  cough  which  he 
has  seems  to  shake  and  hurt  the  lower  belly.  Tongue  coated,  but  food 
taken  fairly  in  small  quantities.  Has  had,  for  instance,  a  little  partridge 
to-day.  Pulse  and  temperature  normal.  Breath  sweet.  Ankles  not 
puffy.     Dulness  all  over  hypogastrium. 

7th,  9.30  A.M. — Good  night.  Pulse  natural.  Temperature  97°.  No 
stupor  or  headache.  Sense  of  a  movable  tumor  in  lower  abdomen.  A 
few  drops  of  urine,  perhaps  a  teaspoonful,  accumulated  after  repeated 
efforts.  10  P.M. — Complains  of  weight  at  lower  belly  on  left  side,  and 
pain  there  on  coughing.  Sickly  during  the  day.  Pulse  and  tempera- 
ture normal.     No  ursemic  symptoms. 

8th,  9th,  and  10th. — Same  report,  unless  there  be  a  little  drowsiness 
and  tendency  to  be  a  little  "lost"  at  times. 

11th. — This  morning  a  little  urine  was  passed,  quantity  not  recorded. 
There  is  a  good  deal  of  mental  oppression,  especially  after  awaking. 
Aspect  dull  and  heavy.  Pupils  contracted.  Dulness  of  abdomen  about 
the  same ;  it  is  a  little  increased  on  left  side,  but  diminished  a  little  to 
the  right.     He  has  been  purged  to-day  without  medicine. 

12th. — Has  passed  ^ivss  of  water,  and  there  is  a  little  less  mental  ob- 
fuscation.  Has  had  a  warm  bath,  which  relieved  him  in  every  way.  Is 
still  purged  also,  an  action  which  is  not  prevented.  Tongue  loaded, 
appetite  nil.     Temperature  normal. 

13th. — Marked  improvement;  a  copious  flow  of  urine  last  night. 
The  head  clear;  a  refreshing  night.  Some  return  of  appetite.  Ab- 
normal dulness  much  diminished. 

14th  and  15th. — A  good  deal  of  pain,  dragging  and  paroxysmal; 
chiefly  in  the  old  place,  above  and  to  left  of  pubis ;  is  irritable  and  rest- 
less; expression  worn  and  anxious.  There  is  no  pain  at  the  end  of  the 
penis.  Pulse  100,  weak.  Temperature  100°.  As  the  water  is  now  very 
abundant,  we  are  able  to  give  him  champagne  and  morphia  injections, 
which  with  warm  water  baths  relieve  him.     Is  still  purged. 

16th  and  17th. — Pains  cease.    No  stone  is  discovered.    Convalescence. 

21st. — May  be  considered  well.  Functions  normal.  Appetite  good. 
No  dulness  in  abdomen. 

I  strongly  suspect  that  the. suppression  in  this  man  was  not  due 
to  the  impaction  of  a  calculus  in  the  ureter,  as  seems  to  have 
been  the  impression  of  Mr.  Wheelhouse  and  Dr.  Allbutt,  but  to 
the  existence  of  a  double  hj^dronephrosis,  and  that  the  case  was 
similar,  pathologically,  to  one  which  fell  under  my  notice  some 
three  years  ago,  and  which  will  be  related  hereafter  (see  hydro- 


SUPI'UKSSIOISr    OF    UKJNK.  71 

iie[)lii'08is,  case  of  J.  S.).  Tcriiporiiry  .suppression  of  urine, 
exteiidini!;  over  some  days,  followed  by  copious  flow  of  urine,  is 
a  distinctive  feature  of  cases  of  hydronephrosis;  and  the  exten- 
sive dulncss  in  the  abdomen,  which  disappeared  after  the  urine 
began  to  How,  can  (the  bladder  being  emptied)  scarcely  be 
otherwise  explained. 

In  the  next  case,  however,  the  suppression  was  undouijtedly 
due  to  the  impaction  of  calculi  in  the  ureter,  and  ceased  when 
these  were  voided. 

Case  6.  (From  the  notes  of  Dr.  Duigan.) — The  patient  was  a  strong, 
stout,  middle-aged  cattle-jobber,  living  in  the  country.  He  had  often 
suffered  from  renal  colic,  and  had  frequently  passed  uric  acid  calculi. 
The  attack  began  with  pain  in  both  loins,  and  the  patient  had  had  com- 
plete suppression  for  three  or  four  days  when  first  seen  by  Dr.  Duigan, 
in  consultation  with  Dr.  Smallman,  of  Willingham.  The  pain  had  then 
completely  subsided,  and  except  for  loss  of  appetite  and  the  suppres- 
sion, the  man  presented  no  marked  symptoms.  The  introduction  of  a 
catheter  showed  that  the  bladder  was  empty.  For  nine  days  he  con- 
tinued in  this  state,  never  passing  any  urine  all  that  time,  and  not  suffer- 
ing from  any  bad  symptoms,  sickness,  or  other  indications  of  ureeraic 
poisoning.  At  the  end  of  this  period  the  kidneys  began  to  act,  and  he 
j)assed  a  quantity  of  clear  urine  of  low  specific  gravity,  containing 
nothing  abnormal.  With  this  urine  he  voided  three  or  four  uric  acid 
calculi,  and  shortly  after  got  quite  well. 

In  this  case  it  is  probable  that  one  kidney  had  been  destroyed 
at  some  former  period  by  the  impaction  of  a  calculus  in  its 
ureter;  at  the  same  time  it  is  not  absolutely  impossible,  as  Dr. 
Duigan  suggests,  though,  I  think,  highly  improbable,  that  both 
kidneys  may  have  been  sound,  and  that  both  ureters  were 
obstructed  by  calculi  at  the  same  moment. 

Case  7. — A  man,  set.  59,  was  visited  by  me  with  Dr.  Herbert  Een- 
shaw,  of  Sale,  on  July  10,  1871.  Six  months  before  he  began  to  suffer 
from  pain  in  his  back,  loss  of  appetite,  failure  of  strength,  and  consti- 
pated bowels.  The  pain  in  the  back  was  of  a  constant  and  severe  ach- 
ing character,  requiring  endermic  injection  of  morphia  for  its  relief. 
The  urine  was  pale  and  abundant,  but  discharged  irregularly.  It  did 
not  at  any  time  up  to  my  visit  contain  blood  or  albumen. 

A  month  before,  the  patient  had  total  suppression  of  urine  for  four 
days.  This  was  overcome  by  compulsorily  walking  him  about  between* 
two  assistants.  The  urine  returned  and  the  pain  subsided.  After  this, 
however,  the  discharge  of  urine  was  extremely  irregular,  and  it  was 
noticed  that  when  the  urine  flowed  freely  the  pain  in  the  back  was  re- 
lieved, and  that  the  pain  became  aggravated  when  the  urine  was  for  a 
time  suppressed. 

After  the  above-mentioned  four  days'  suppression,  he  recovered  a 
good  deal,  and  went  to  Southport.  There  he  was  attacked  with  diar- 
rhoea, and  had  to  return  home  in  consequence. 


72  PHYSICAL    PROPERTIES    OF    THE    URINE. 

At  the  date  of  my  visit  he  was  suffering  severely  from  the  pain  in  the 
back;  he  was  very  weak,  and  his  legs  were  slightly  oedematous.  He 
was  then  passing  from  one  to  two  pints  of  a  dilute  urine  daily;  this  con- 
tained a  trace  of  albumen.  I  requested  that  all  the  urine  which  the 
patient  voided  should  be  collected  and  brought  to  me  day  by  day  for 
the  next  three  days.  The  first  day  he  voided  two  pints,  the  second  day 
one  pint,  and  the  third  day  eight  ounces.  For  the  next  three  days  the 
urine  was  totally  suppressed,  and  he  died.  The  specimens  of  urine  were 
all  alike ;  they  vv'ere  pale  and  watery,  the  specific  gravity  ranged  from 
1009  to  1010;  they  were  acid,  and  contained  a  trace  of  albumen. 

The  symptoms  during  the  last  three  days  of  life  were  as  follows, 
according  to  the  statements  of  Dr.  Renshaw  and  the  patient's  wife,  for 
I  saw  him  only  once  myself:  Increased  weakness,  marked  panting 
breathing  ;  diarrhoea  for  the  last  two  days ;  twitchings  of  the  muscles ; 
rambling  delirium  when  left  to  himself,  but  perfect  consciousness  to  the 
last  when  his  attention  was  roused ;  no  coma,  no  convulsions. 

Autopsy. — Body  quite  free  from  urinous  or  ammoniacal  odor.  All  the 
organs  were  healthy  except  the  urinary  apparatus.  The  source  of  mis- 
chief was  found  to  be  a  hard  scirrhous  mass,  as  large  as  an  orange,  which 
half  filled  the  pelvis.  This  growth  involved  the  base  of  the  bladder 
and  the  prostate  gland.  The  rectum  was  adherent  to  it  and  constricted 
for  the  space  of  an  inch ;  but  I  could  get  two  fingers  through  the  nar- 
rowest part.  The  seat  of  the  scirrhous  growth  in  the  bladder  was  the 
submucous  tissue.  Neither  the  mucous  nor  peritoneal  coats  were  impli- 
cated, though  much  puckered  and  folded,  owing  to  the  contraction  of 
the  thickened  wall  of  the  bladder.  The  whole  trigone  was  involved,  and 
the  disease  extended  for  a  full  inch  above  the  trigone,  terminating  in  a 
thick,  abrupt  rim  or  border.  The  walls  of  the  bladder  in  the  implicated 
region  measured  from  half  to  three-quarters  of  an  inch  in  thickness. 
The  fundus  of  the  bladder  was  quite  healthy,  and  the  organ  was  capable 
of  containing  about  half  a  pint  of  urine.  The  urethra  for  the  length  of 
an  inch  passed  through  the  dense  mass  of  the  prostate,  which  was  fully 
an  inch  and  a  half  thick.  The  channel  was  quite  free,  a  catheter  had 
been  repeatedly  passed  during  life  without  any  difiiculty. 

The  terminal  portions  of  both  ureters  passed  for  the  length  of  an  inch 
through  the  scirrhous  mass;  their  course  in  this  part  was  tortuous,  and 
their  channel  compressed  by  the  surrounding  growth,  but  a  probe  could 
be  insinuated  through  both  of  them,  showing  that  neither  w^as  completely 
occluded.  Above  the  bladder  both  ureters  were  dilated  to  the  size  of 
the  little  finger  (the  left  more  than  the  right),  and  distended  with  urine. 
The  left  kidney  was  greatly  atrophied,  and  weighed  only  2}  oz. ;  the  inte- 
rior was  hollowed,  without  trace  of  pyramids,  and  the  cortical  substance 
was  reduced  to  a  fleshy  rim  of  tissue  of  homogeneous  appearance.  The 
right  kidney  was  enlarged,  and  weighed  7  oz. ;  it  was  hollowed,  but  not 
so  completely  as  its  fellow.  The  pyramids  were  gone,  and  the  cortical 
substance  was  undergoing  absorption.  The  pelvis  was  enlarged  to  the 
size  of  an  egg,  and  distended  with  urine. 

It  was  evident  that  the  left  kidney  had  not  done  any  duty  for  some 
months,  and  that  life  had  been  sustained  by  the  hypertrophied  right 
kidney  until  its  ureter  also  was  blocked  up  by  the  progress  of  the  growth 
in  the  bladder. 


SUPPRESSION    OF    URINE.  Y--) 

The  tumor  had  contracted  adhesions  to,  and  made  extensions  into,  the 
adjacent  parts  in  the  pelvis.  The  iliac  vessels  passed  through  a  dense 
scirrhous  mass,  whereby  they  must  have  been  more  or  less  compressed  ; 
this  was  evidently  the  cause  of  the  oedema  of  the  legs. 

My  notes  of  the  next  two  cases  are  imperfect,  but  as  oacli  of 
them  illustrates  some  point  in  the  historj'  of  obstructive  suppres- 
sion, I  will  add  them  to  the  series. 

Case  8. — This  was  an  old  lady  of  about  60,  whom  I  saw  with  Dr. 
Gardiner,  of  Ashton.  She  was  afflicted  with  cancerous  disease  of  the 
uterus  and  vagina,  involving  the  base  of  the  bladder  and  (presumably) 
implicating  the  terminal  portions  of  the  ureters.  When  I  visited  her 
no  urine  had  been  passed  for  four  days,  and  the  suppression  continued 
without  interruption  for  three  days  longer,  altogether  a  total  of  seven 
days.  After  this  the  urine  returned,  and  flowed  normally  for  the  re- 
maining four  weeks  during  which  she  lived.  During  the  time  of  sup- 
pression there  were  great  restlessness  and  insomnia,  with  a  flushed  and 
anxious  expression  of  countenance,  but  no  twitchiugs  of  the  muscles, 
a,nd  no  convulsions  nor  coma.     There  was  no  autopsy. 

Seven  days  of  suppression  of  urine,  without  the  development 
of  urse-.mic  symptoms,  and  issuing  in  recovery  so  far  as  the  sup- 
pression was  concerned,  is,  as  we  have  seen,  not  an  unprecedented 
occurrence.  It  may  be  conjectured  that  in  this  case  one  ureter 
was  permanently  occluded  by  the  morbid  growth ;  and  that 
during  the  epoch  of  suppression  the  opposite  ureter  had  become 
blocked  up,  probably  by  a  fungous  excrescence  projecting  into 
its  calibre,  and  that  an  ulcerative  process  at  the  end  of  seven 
days  again  cleared  the  passage.  This  is  a  process  analogous  to 
that  which  sometimes  occurs  in  scirrhus  of  the  pylorus,  when 
the  strictured  state  prevailing  in  the  earlier  periods  is  after- 
wards removed  by  the  softening  and  ulcei-ation  of  a  portion  of 
the  cancerous  mass. 

Case  9. — A  man  of  about  35,  greatly  given  to  alcoholic  excesses,  was 
seen  by  me  on  January  15, 1869.  He  had  then  passed  no  urine  for  four 
days.  He  was  somewhat  stout,  and  both  loins  weie  doubtfully  thought 
to  be  the  seat  of  bulging,  of  an  elastic,  quasi-fluctuating  character.  The 
previous  history  threw  no  light  w^hatever  on  the  nature  of  the  case. 
There  were  no  ursemic  symptoms,  but  a  great  sense  of  tension  of  the 
abdomen.  I  saw  this  man  on  three  successive  days,  and  introduced  a 
tubular  needle  to  the  depth  of  three  inches  into  one  of  the  lateral  bulg- 
ings,  but  without  reaching  any  collection  of  fluid.  The  notion  I  enter- 
tained was  that  a  double  hydronephrosis  existed,  and  that  the  swellings 
in  the  loins  were  the  sacculated  kidneys  distended  with  urine.  He  died 
two  days  after  my  last  visit.  No  post-mortem  examination  was  per- 
mitted. The  suppression  lasted  nine  days,  and  during  that  jieriod  only 
about  an  ounce  of  urine  was  voided,  which  was  said  to  be  pale.     Up  to 


74  PHYSICAL    PROPERTIES    OF    THE    UPINE. 

the  seventh  clay  of  suppression  there  were  no  twitchings  of  the  muscles 
nor  marked  contraction  of  the  pupils.  The  information  respecting  the 
final  symptoms  is  defective.  There  were  great  restlessness  and  insomnia. 
Consciousness  was  maintained  to  the  last,  and  the  patient  asked  to  be 
prayed  with  just  before  his  death. 

The  foUowina^  case  is  remarkable  in  two  respects — namely, 
the  long  survival  of  the  patient  (15  days)  and  the  occurrence  of 
transient  anasarca. 

Case  10. — Mrs.  P.,  set.  56,  had  been  suffering  for  18  months  from 
occasional  uterine  hemorrhage,  due  to  scirrhus  of  the  os  and  cervix  uteri. 
On  January  15,  1876,  the  urine  became  very  scanty,  and  next  day  it 
altogether  ceased.  From  this  date  to  the  day  of  her  death,  on  January 
30th,  not  a  drop  of  urine  was  secreted.  I  saw  her  on  the  tenth  day  of 
suppression,  with  my  friend  Dr.  Lloyd-Roberts,  to  whom  I  am  indebted 
for  the  notes  of  her  case.  Her  condition  was  singularly  calm.  She  took 
her  food,  and  slept  well ;  the  tongue  was  moist  and  the  pupils  natural. 
Pulse  84 ;  temperature  99°.  There  was  no  pain  anywhere.  Dr.  Roberts 
informed  me  that  on  the  first  two  days  of  suppression  there  was  slight 
general  anasarca — most  marked  in  the  face.  This  symptom  entirely 
passed  off  on  the  third  day;  but  there  was  a  slight  recurrence  of  oedema 
in  the  feet  on  the  day  before  death. 

On  making  a  digital  examination,  an  extensive  scirrhous  growth  was 
found,  involving  the  cervix  uteri  and  the  adjoining  part  of  the  vagina 
corresponding  to  the  base  of  the  bladder.  This  explained  the  suppres- 
sion ;  the  ureters,  as  they  passed  through  the  trigone,  were  doubtless 
involved  in  the  cancerous  growth,  and  thereby  occluded.  The  bladder 
was  found  empty. 

The  symptoms  continued  almost  unchanged  until  January  29th.  On 
that  day  she  became  worse.  The  pupils  became  contracted ;  and  mus- 
cular twitches  were  observed  in  the  face.  The  muscular  power  failed 
rapidly,  first  in  the  arms  and  legs,  and  lastly  in  the  trunk.  She  died 
quietly  on  the  morning  of  January  30th,  apparently  from  paralysis  of 
the  respiratory  muscles.  The  temperature  on  the  29th  sank  one  degree 
below  the  normal.     No  autopsy  was  permitted. 

The  duration  of  life  in  complete  obstructive  suppression  appears 
to  range,  as  a  rule,  from  nine  to  eleven  days,  and  the  passage  of 
a  few  ounces,  or  even  two  or  three  pints,  of  a  dilute  urine  does 
not  seem  to  extend  the  time  of  survival  beyond  a  few  hours. 
I  have  not  discovered  more  than  four  well-authenticated  cases 
(in  addition  to  the  one  just  related — Case  10)  in  which  suppres- 
sion of  urine  was  complete,  or  approached  completeness,  where 
the  patient  survived  beyond  the  eleventh  day.  The  first  of  these 
is  recorded  by  Rayer  {Mai.  des  Reins,  t.  iii.  p.  490).  The  patient 
was  a  man  of  64  years  of  age,  who  had  hydronephrosis  of  the 
right  kidney  of  many  years'  standing.  The  ureter  of  the  left 
kidney  was  blocked  up  by  a  calculus,  and  suppression  of  urine 


SUrPKESSlON    OF    URINE.  75 

ensued.  TIj'ih  proved  fatal  in  twenty-five  days,  and  in  tliat  in- 
terval oidy  two  oun(;es  of  urine  were  voided.  The  necond  case 
is  described  by  Sir  J.  Paget  in  the  second  volume  of  the  Trans- 
actions of  the' Clinical  Society.  The  patient  was  seventy-three 
years  of  age.  The  right  kidney  was  atrophied  and  apparently 
incapable  of  secreting  any  normal  urine.  The  left  kidney  was 
hypertrophied  and  the  ureter  blocked  by  a  stone.  Complete 
suppression  ensued  for  thirteen  days.  ISTo  symptoms  of  urfcmic 
poisoning  appeared  until  the  last  of  these  thirteen  days,  when  a 
slight  attack  of  convulsions  occurred.  Then,  on  the  fourteenth 
day,  he  passed  an  uncertain  but  "  considerable "  quantity  of 
urine,  and  again  six  ounces  on  the  same  day;  some  slight  con- 
vulsive movements  which  had  been  observed  during  the  day 
then  ceased.  From  this  period  until  his  death,  seven  days  after- 
wards, the  suppression  was  complete,  and  no  urine  was  found  in 
the  bladder  after  death.  So  that  there  was  total  suppression 
for  twenty-one  days,  only  interrupted  by  one  day's  emission  of 
urine.  Muscular  twitchings  made  their  appearance  on  the  six- 
teenth day.  Sir  J.  Paget  attributed  the  extraordinary  protraction 
of  life  in  this  case  mainly  to  the  patient's  advanced  age ;  but 
this  view  is  scarcely  borne  out  by  other  experience.  My  first 
patient  was  sixty-seven  —  only  six  years  younger  than  Sir  J. 
Paget's  case,  yet  he  only  survived  nine  and  a  half  days,  though 
he  secreted  sixty  ounces  of  urine  in  that  period. 

A  third  case  is  reported  by  Dr.  Eussell  in  the  31ed.  Times  and 
Gazette,  1879,  i.  p.  474,  where  the  patient,  after  complete  obstruc- 
tive suppression  lasting  twenty  days,  recovered  for  a  time,  but 
died  afterwards.  There  was  excessive  vomiting  and  also  gen- 
eral oedema.  A  post-mortem  examination  show^ed  the  presence 
of  calculi  in  the  pelvis  of  each  kidney,  blocking  the  ureter. 

Tenneson  {Gfaz.  Hebdomad.,  1879)  reports  a  case  in  which  the 
suppression  of  urine  lasted  fifteen  days  before  death  ensued. 
OEdema  was  also  present  in  this  case. 

There  are,  indeed,  other  cases  on  record,  in  the  more  ancient 
literature  of  medicine,  in  which  patients  are  alleged  to  have 
survived  many  months  of  total  suppression  of  urine;  but  it  may 
be  safely  affirmed  that  imposition  of  some  sort  or  other  was 
practised  in  these  cases. 

Treatment. — Our  notions  of  the  treatment  must  vary  accord- 
ing to  the  nature  of  the  obstruction.  Taking  first  those  cases 
which  are  due  to  impaction  of  a  stone  in  the  ureter,  it  must 
appear  that  the  use  of  ordinary  diuretics  cannot  avail  against  a 
physical  obstacle.  Eeliquet^  has  recorded  a  successful  case  in 
which  he  applied  gutta-percha  bands  to  the  limbs,  with  a  view 
of  increasing  the  blood  pressure  in  the  kidneys.     There  is  some- 

1  Union  Medicale,  Xos.  69  and  70. 


76  PHYSICAL    PROPEETIES    OF    THE    URINE. 

thing  to  be  said  in  favor  of  means  directed  to  excite  the  con- 
tractile power  of  the  ureter.  In  my  second  case  Dr.  Garrod 
suggested,  with  this  view,  the  use  of  turpentine,  but  it  provoked 
vomiting  and  could  not  be  persevered  with.  In  a  case  reported 
by  Carrere  {Gaz.  Hehd.,  1879)  ergot  was  given,  recovery  follow- 
ing shortly  afterwards.  Or  remedies  of  an  opposite  class  might 
be  alternately  tried  with  the  purpose  of  relaxing  the  spasm  of 
the  ureter,  such  as  opium,  chloroform,  belladonna,  venesection, 
and  warm  baths.  My  own  impression,  however,  is  more  in 
favor  of  mechanical  means;  and  in  reviewing  the  cases  which 
have  fallen  under  my  notice,  I  cannot  help  thinking  that  some- 
thing further  might  have  been  attempted  in  this  way  with  a 
prospect  of  advantage.  One  such  means,  namely,  kneading  and 
shampooing  the  renal  region  and  the  course  of  the  ureter,  was 
in  two  of  my  cases  followed  by  a  so  immediate,  though  only 
transient,  flow  of  urine,  that  I  could  scarcely  doubt  that  it  was 
due  to  the  means  employed.^  But  in  a  large  number,  if  not  the 
majority  of  cases  the  impaction  takes  place  near  the  bladder, 
where  no  direct  force  can  be  applied.  Indirect  means  may, 
however,  be  tried.  The  physical  condition  is  generally  this : 
Above  the  calculus  the  ureter  is  open  and  distended  with  stag- 
nant urine  ;  at  the  seat  of  the  lodgement,  and  below  it,  the  ureter 
is  contracted.  A  displacement  either  upwards  or  downwards 
would  be  likely  to  be  followed  by  relief.  To  provoke  such  dis- 
placement, succussion  of  the  body  and  various  changes  of  posture 
might  be  tried.  The  patient  should  be  directed  to  support  him- 
self from  time  to  time  on  his  knees,  with  the  upper  half  of  the 
body  depressed,  and  the  sacrum  might  be  repeatedly  struck  with 
the  fist.  The  force  of  gravity  would  thus  be  brought  in  aid  to 
coax  the  obstacle  back  toward  the  kidney.  Or  walking  the 
patient  between  two  assistants  up  and  down  stairs  and  about  the 
room  might  be  practised  in  the  earlier  periods  of  the  case,  with 
the  object  of  facilitating  the  descent  of  the  calculus  into  the 
bladder.  Means  of  this  class  should  be  persevered  in  to  the 
end,  for  experience  is  warrant  that  hopes  may  be  entertained, 
even  almost  to  the  last,  that  the  obstruction  may  be  yet  over- 
come. 

VI.— EEACTION  OF  THE  UEINE. 

There  is  no  property  of  the  urine  of  more  varied  and  im- 
portant significance  than  its  reaction.  Therewith  is  intimately 
connected  the  occurrence  of  several  kinds  of  urinary  deposits, 
together  with  the  origin,  growth,  and  medical  treatment  of 
gravel  and  urinary  calculi. 

^  Lately  it  has  been  recommended  to  open  the  ureter  or  the  pelvis  of  the  kidney 
above  the  obstruction,  and  so  establish  a  permanent  urinary  fistula.  [See  Brit. 
Med.  Journ.,  Dec.  1883.) 


REACTION    OF    THE    URINE  77 

The  reaction  of  the  urine  is  liable  to  be  affected  by :  /oo<-/,  the 
cold  hath,  medicinal  suhstances,  general  dJse.ase,  and  drcdnipofiiiioii  of 
the  secretion.  It  is  also  important  not  only  to  distinguish  acid 
from  alkaline  urine,  but  it  is  at  least  equally  so  to  distinguish 
between  alkalescence  from  fixed  alkali  (potash  and  soda)  and 
alkalescence  from  the  volatile  alkali  (ammonia). 

The  most  convenient  method  of  ascertaining  the  reaction  of 
the  urine  is  by  means  of  blue  and  red  litmus  paper.  For  deli- 
cate operations  the  violet-tinted  papers  are  the  best;  and  they 
answer  both  for  acid  and  alkaline  fluids — being  turned  red  by 
the  former  and  blue  by  the  latter.  To  distinguish  between  the 
volatile  and  fixed  alkali,  the  paper,  aftej  being  rendered  blue, 
should  be  allowed  to  dry  in  the  open  air.  If  the  blue  color 
persist  after  complete  desiccation,  the  alkali  is  fixed ;  if  it  dis- 
appear, and  the  original  color  be  restored,  the  alkalescence  is 
due  to  ammonia.  The  smell  of  the  urine  is  also  a  useful  indi- 
cation in  such  cases. 

Healthy  urine  is  generally  acid.  This  arises  chiefly  from 
the  presence  of  a  number  of  acid  salts — phosphates  and  urates; 
partly  also  from  free  acids — lactic,  oxalic,  acetic,  etc.  In  a 
number  of  observations  by  the  present  writer,  it  was  found,  on 
an  average  of  nineteen  days,  that  in  a  healthy  man  it  required 
14.10  grains  of  dried  carbonate  of  soda  to  saturate  the  total 
daily  acidity  of  the  urine.  Some  days  were  found  throughout 
to  exhibit  a  feeble  acidity;  on  one  of  these  only  5.9  grains  of 
dried  carbonate  of  soda  were  necessary  to  neutralize  the  whole 
acidity.  On  other  days  the  acidity  ruled  high  ;  one  day  the 
acidity  equalled  22.34  grains  of  carbonate  of  soda. 

The  circumstances  which  modify  the  reaction  of  the  urine 
may  be  considered  under  the  following  headings  : 

1.  Food  and  Fasting. — Dr.  Bence  Jones  was  the  first  to  point 
out  that  the  reaction  of  the  urine  holds  a  close  relation  to  the 
digestion  of  food.  He  found,  by  examining  the  urine  at  short 
intervals,  that  a  notable  falling  off  in  its  acidity  took  place  after 
a  meal ;  and  that  in  numbers  of  healthy  persons  the  urine  became 
neutral  or  alkaline  for  two  or  three  hours  after  breakfast  and 
dinner.  Doubts  have  been  thrown  on  the  conclusions  of  Dr. 
Bence  Jones  bj'  Vogel,  Beneke,  Sellers,  and  Delavaud.  Some 
years  ago  I  undertook  a  series  of  experiments  with  a  view  of 
submitting  this  question  to  a  fresh  examination.^  The  urine  of 
a  healthy  person  w^as  examined  at  hourly  periods  after  a  meal, 
and  its  acidity  or  alkalescence  carefully  determined  by  volu- 
metrical  analysis.  My  results  confirmed,  in  the  fullest  manner, 
the  observations  of  Dr.  B.  Jones.     A  meal,  whether  of  animal, 

1  See  a  paper  by  the  author,  entitled  "A  Contribution  to  Urology,"  in  the 
Memoirs  of  the  Manchester  Lit.  and  Phil.  Soc,  1859. 


78  PHYSICAL    PROPERTIES    OF    THE    URINE. 

vegetable,  or  mixed  food,  was  found  invariably  to  depress  the 
acidity  of  the  urine,  and  in  most  instances  to  render  it  actually 
alkaline.  To  this  movement  the  name  of  alkaline  tide  maj^,  for 
the  sake  of  brevity,  be  applied.  After  breakfast  the  alkaline 
tide  was  found  to  set  in  earlier  than  after  dinner,  and  its  dura- 
tion was  more  brief.  In  forty  minutes  after  breakfast  there 
appeared,  nearly  always,  a  sensible  declension  of  ac^dit^^  The 
urine,  however,  never  became  actually  alkaline,  or  even  neutral, 
so  soon.  During  the  second  hour  after  breakfast,  the  alkaline 
tide  usually  culminated ;  but  in  about  a  third  of  the  observa- 
tions the  point  of  least  acidity  was  not  reached  until  the  third 
hour.  Then  the  tide  turned ;  during  the  fourth  hour  the  urine 
was  found  to  be  rapidly  recovering  its  lost  reaction,  and  toward 
the  end  of  that  time  it  had  usually  regained  its  original  acidit3^ 
Thus  for  about  four  hours  breakfast  exercised  a  depressing  effect 
on  the  acidity  of  the  urine;  but  the  secretion  was  not  actually 
alkaline  usually  for  more  than  an  hour,  sometimes  for  two,  and 
very  rarely  for  three  hours. 

The  effect  of  dinner  was  not  perceptible  until  the  second  hour 
after  the  meal.  During  the  succeeding  three  hours  (third, 
fourth,  and  fifth  hours)  the  alkaline  tide  ran  in  its  greatest 
strength.  In  the  third  and  fourth  hours  the  urine  was  always 
(with  two  exceptions)  alkaline,  when  the  meal  had  been  of  naixed 
food  or  animal  diet.  At  the  end  of  the  sixth  hour  the  tide  had 
generally  turned,  and  the  acid  reaction  been  restored.  Three 
hours  was  the  usual  duration  of  the  alkalescent  state  after 
dinner ;  sometimes  two  hours ;  more  rarely  four  hours ;  and  on 
one  occasion  five  hours.  The  amount  of  free  alkali  discharged 
after  dinner  was  generally  nearly  double  the  quantity  after 
breakfast.  This  was  due,  probably,  to  the  fact  that  dinner  was 
usually  a  much  heavier  meal  than  breakfast,  and  its  impression 
on  the  system  consequently  more  intense. 

The  alkaline  urine  voided  after  food  owed  its  reaction  to  fixed 
alkali,  and  not  to  ammonia.  It  was  rich  in  earthy  and  alkaline 
phosphates.  Sometimes  it  was  clear  when  voided,  but  more 
commonly  turbid,  from  the  precipitation  of  earthy  phosphates. 

Although  the  immediate  effect  of  a  meal  was  thus  to  depress 
the  acidity  of  th6  urine,  the  more  remote  consequence  was  to  main- 
tain and  even  increase  the  acidity.  This  was  seen  most  dis- 
tinctly when  comparison  was  made  of  the  acidity  of  the  morning 
urine,  when  supper  had  been  taken  the  night  before,  with  that 
of  the  morning  urine  when  no  supper  had  been  taken.  In  the 
former  case  the  free  acid  discharged  in  the  hour  preceding  break- 
fast was  enough  to  saturate  0.88  grain  of  dried  carbonate  of 
soda :  whereas  on  the  mornings  after  supperless  nights  the  dis- 
charge of  acid  was  only  equal  to  0.51  grain. 

The   remote   effect   of    animal    food   appeared   considerably 


REACTION    OF    THE    URINE.  79 

greater  than  that  of  vegetable  food  :  80  that  a  highly  animalized 
diet  would  tend  in  the  long  run  to  intenHify  the  acidity  of  the 
urine — a  conclusion  quite  in  harmony  with  ancient  opinion. 

Clinically,  the  urine  is  rarely  observed  to  be  alkaline  after 
food.  For,  although  it  may  be  alkaline  as  it  leaves  the  kidneys 
during  several  hours  a  day,  after  the  two  principal  meals,  it  is 
mixed  in  the  bladder  with  acid  urine  secreted  before  and  after 
the  alkaline  tide,  and  the  whole  product  ejected  by  micturition 
is  acid.  It  is  necessary,  therefore,  in  order  to  test  the  effect  of 
a  meal,  to  analyze  the  secretion,  as  it  were,  by  examining  it  at 
hourly  intervals.  It  happens  occasionally,  however,  that  the 
urine  of  an  ordinary  micturition  is  the  isolated  product  of  the 
alkaline  tide.  I  have  known  even  a  calculous  patient,  whose 
urine  habitually  deposited  large  quantities  of  uric  acid,  to  void 
an  alkaline  urine  in  the  forenoon  from  the  effect  of  breakfast. 

Dr.  B.  Jones  considered  the  depression  of  the  acidity  of  the 
urine  after  a  meal  to  depend  on  the  withdrawal  of  acid  from  the 
blood  into  the  stomach  for  the  purposes  of  digestion  :  whereby 
the  blood  became  for  the  time  less  capable  of  yielding  acid  to 
the  kidneys.  On  the  completion  of  digestion  the  gastric  juice 
was  re-absorbed  with  the  chyle  and  presently  communicated  its 
acid  to  the  urine.  An  antagonism  was  thus  supposed  to  exist 
between  the  stomach  and  kidneys ;  when  the  stomach  was  empty 
its  mucous  membrane  was  neutral,  while  the  urine  on  the  con- 
trary was  highly  acid;  but  when  the  stomach  was  full,  acid 
gastric  juice  was  abundantly  poured  out  on  its  mucous  surface 
for  the  purposes  of  digestion,  and  at  the  same  time  the  urine 
tended  towards  neutrality  or  alkalescence. 

While  admitting  the  strong  probability  of  some  such  corre- 
spondence, I  am  disposed  to  attribute  the  occurrence  of  the  alka- 
line tide  after  meals  mainly  at  least  to  a  different  cause — namely, 
to  the  entrance  of  the  newly  digested  food  into  the  blood.  If, 
as  is  believed,  the  normal  alkalescence  of  the  blood  is  due  to  the 
preponderance  of  alkaline  bases  in  all  our  ordinary  articles  of 
food,  a  meal  is  pro  tanto  a  dose  of  alkali,  and  must  necessarily, 
for  a  time,  add  to  the  alkalescence  of  the  blood ;  and  as  the 
kidneys  have  delegated  to  them  the  function  of  regulating  the 
reaction  of  the  blood,  the  urine  immediately  reflects  any  undue 
addition  to,  or  subtraction  from,  the  blood's  proper  alkalescence. 
This  hypothesis  is  mainly  supported  by  the  coincidence  of  titHe 
w^hich  exists  between  the  j)assage  of  the  digested  food  into  the 
blood  and  the  occurrence  of  the  alkaline  tide.  The  gastric 
juice  is  poured  into  the  stomach  immediately  after  a  meal,  but 
the  acidity  of  the  urine  does  not  suffer  depression  for  an  hour 
or  two  afterwards — not  in  fact  until  the  meal  has  been  in  great 
part  absorbed. 

After  the  primary  effect  of  a  meal  has  passed  off",  the  acidity 


80  PHYSICAL    PEOPERTIES    OF    THE    URINE. 

of  the  urine  slowly  increases  until  food  is  taken  again.  The 
highest  acidity  is,  therefore,  always  found  after  the  longest  fast- 
ing, or  just  before  meals.  In  the  early  morning  before  break- 
fast, the  urine  was  always  found  excessively  acid,  and  deposited 
abundance  of  urates  on  cooling.  There  seems,  however,  a  limit 
to  the  increase  of  the  acidity  after  prolonged  fasting;  Dr.  Bence 
Jones  found  that  continuing  to  fast  for  twelve  hours  beyond  the 
usual  time  of  taking  food  did  not  intensify  the  acidity  of  the 
urine. 

2.  Eppects  of  Medicines. — Both  mineral  and  vegetable  adds, 
when  administered  in  large  quantities,  tend  to  raise  the  acidity 
of  the  urine;  but  their  effect  is  inconsiderable.  Urine  that  is 
habitually  alkaline  can  certainly  not  be  rendered  acid  by  the 
internal  administration  of  acids  even  in  very  large  quantities.^ 
The  most  powerful  acidifiers  of  the  urine  are  probably  free  car- 
bonic acid  (Heller)  and  benzoic  acid;  the  latter  appears  in  the 
urine  as  hippuric  acid. 

Alkaline  substances  have  a  much  more  powerful  influence;  and 
it  is  an  easy  matter  to  deprive  the  urine  of  its  acid  reaction  and 
to  render  it  strongly  alkaline  at  pleasure.  This  effect  may  be 
attained  by  the  caustic  and  carbonated  alkalies,  or  by  the  alka- 
line salts  of  a  certain  group  of  vegetable  acids — acetic,  tartaric, 
citric,  malic,  and  lactic  acids.  The  most  convenient  for  the 
purpose,  as  well  as  the  least  disturbing  to  the  digestive  organs, 
are  the  bicarbonates  of  potash  and  soda,  and  the  acetates  and 
citrates  of  the  same  bases.  By  the  administration  of  these  salts 
the  urine  may  be  kept  persistently  alkaline  for  weeks  and 
months  without  detriment  to  the  general  health.  It  requires 
from  300  to  400  grains  of  the  bicarbonate  of  potash,  and  about 
as  much  of  the  acetate  and  citrate,  given  in  divided  doses  during 
the  twenty-four  hours,  to  keep  the  urine  steadily  alkaline  in  the 
adult.  From  numerous  observations  on  different  individuals,  I 
found  that,  given  in  these  large  doses,  about  two-thirds  of  the 
alkali  appeared  in  the  urine  as  free  carbonate;  while  the  remain- 
ing third  was  expended  in  neutralizing  the  acidity  of  the  urine 
and  otherwise  disposed  of.  The  conversion  of  the  acetates, 
citrates,  etc.,  into  carbonates,  which  was  shown  long  since  to 
occur  by  Wohler,  takes  place,  according  to  Buchheim  and 
Magawley,  in  the  intestinal  canal,  and  the  salts  in  question  are 
therefore  absorbed  into  the  blood  as  carbonates.  The  bicarbo- 
nates, acetates,  and  citrates,  if  moderately  diluted,  were  not 
found  to  have  any  tendency  to  cause  diarrhoea;  the  tartrates,, 
on  the  other  hand,  were  always  found  to  occasion  more  or  less 
purging. 

1  For  further  information  on  the  action  of  acids  on  the  urine,  see  Parkes,  "On 
the  Composition  of  the  Urine,"  p.  145  et  seq.  See  also  a  paper  by  Dr.  Benoe 
Jones,  St.  George's  Hosp.  Keports,  1869. 


REACTION    OF    THHJ     UIUNE,  81 

The  basic  phosphate  of  soda,  the  eorrmioii  pliospliate  of  soda, 
and  borax,  likewise  possess  the  power  of  alkalizing  the  urine; 
but  their  eft'ect  is  very  feeble,  compared  with  that  of  the  salts 
before  mentioned.  The  common  phosphate  of  soda,  in  the 
quantity  of  640  grains  in  the  twenty-four  hours,  in  divided  doses, 
produced  a  total  alkalescence  of  the  urine,  only  equal  to  22 
grains  of  carbonate  of  soda;  whereas  half  the  quantity  of  the 
acetate  of  potash  produced  an  all<:alescence  equal  to  120  grains 
of  carbonate  of  soda;  640  grains  of  the  basic  phosphate  of  soda 
produced  an  alkalescence  equal  to  37  grains  of  carbonate  of 
soda;  320  grains  of  borax  gave  an  alkalescence  of  9  grains  of 
carbonate  of  soda;  this  last  salt  proved  difficult  of  toleration  by 
the  stomach. 

The  power  of  alkalizing  the  urine  is  especially  valuable  in 
the  treatment  of  urinary  gravel  and  calculi;  and  to  the  chapter 
on  the  solvent  treatment  of  urinary  concretions  I  must  refer 
the  reader  for  further  details  on  the  subject. 

3.  The  Cold  Bath. — Duriau^  found  that  the  urine  became 
invariably  alkaline  after  prolonged  immersion  of  the  body  in  a 
bath  at  a  colder  temperature  than  that  of  the  body.  Even  the 
addition  of  nitric  acid  to  the  bath  did  not  in  the  least  alter  the 
result;  nor  did  the  addition  of  carbonate  of  potash  cause  an 
increased  alkalescence. 

4.  General  Disease. — Frequent  or  persistent  alkalescence  of 
the  urine,  from  fixed  alkali,  is  an  uncommon  condition  in  any  class 
of  complaints;  but  a  series  of  such  cases  have  been  recorded  by 
Dr.  Bence  Jones,^  and  I  have  observed  a  considerable  number 
myself.  In  persons  of  debilitated  constitutions,  in  the  anaemic 
state  which  sometimes  follows  subacute  rheumatism  and  gout,  in 
chlorosis,  atonic  dyspepsia,  chronic  vomiting,  and  even  in 
chronic  phthisis,  I  have  seen  the  urine  present  this  character. 
Generally,  the  alkalescence  came  and  went  capriciously ;  con- 
tinuing for  two  or  three  days,  and  then  disappearing;  but  pres- 
ently returning  again.  Sometimes,  however,  the  urine  remained 
steadily  alkaline  for  many  weeks  without  intermission.  In  one 
case  of  this  kind — a  phthisical  patient — the  urine  became  acid 
on  the  occurrence  of  an  attack  of  erysipelas  of  the  head  and 
face:  it  remained  acid  during  the  attack,  and  after  its  subsidence 
became  again  alkaline. 

The  clinical  significance  of  alkaline  urine  from  fixed  alkali  is 
by  no  means  serious;  it  is  not  associated  with  any  special 
morbid  state,  but  is  an  occasional  accompaniment  of  debility 
and  span^emia,  from  whatever  cause  arising.  It  is  to  be  remem- 
bered, however,  that  there  is  a  rare  variety  of  urinary  calculus 

1  Archives  Generales,  1856,  I.  167.  " 
-  Med.  Chir.  Trans.,  vol.  xxxv. 


82 


PHYSICAL    PROPERTIES    OF    THE    URINE. 


composed  of  phosphate  of  lime,  which  must  be  caused  by  some 
such  condition  of  urine  as  this.  Individuals  passing  an  alkaline 
urine  are  generally  suitable  subjects  for  a  tonic  and  stimulat- 
ing treatnient:  and,  if  otherwise  permissible,  exercise  in  the 
open  air. 

5.  Ammoniacal  Urine.  Decomposition  of  Urea — The  impor- 
tance of  distinguishing  between  urine  which  is  alkaline  from 
fixed  alkali,  and  that  which  is  alkaline  from  ammonia,  has 
already  been  insisted  on.  The  two  conditions  are  contrasted, 
not  only  chemically,  but  equally  so  pathologically  and  clinically. 

Urine  which  is  alkaline  from  fixed  alkali  is  always  secreted 
alkaline  by  the  kidneys ;  it  deposits,  if  at  all,  simple  amorphous 
phosphate  of  lime,  of  which  the  particles  have  no  tendency  to 
accrete  into  gravel  or  calculi;  it  has  a  sweet  aromatic  odor;  it 
is  perfectly  bland  and  innocuous  to  the  mucous  membranes,  and 
is  not  associated  with  inflammation  of  the  urinary  passages. 

Ammoniacal  urine,  on  the  other  hand,  is  only  in  the  rarest 
instances,  and  in  the  gravest  circumstances,  secreted  ammo- 
niacal   by  the   kidneys,  but  usually  becomes   so   by  an  after- 

FiG.  3. 


The  normal  deposit  from  ammoniacal  urine,  showing  crystals  of  ammoniaco-magnesian  phosiihate, 
amorphous  phosphate  of  lime,  and  spheres  of  urate  of  ammonia. 

change  occurring  in  the  lower  urinary  passages,  or  after  it  has 
been  voided.  Ammoniacal  urine  is  always  sedimentary;  it 
deposits  a  mixture  of  the  amorphous  phosphate  of  lime  and 
crystals  of  the  ammoniaco-magnesian  phosphate — sometimes,  if 
the  urine  be  concentrated,  with  the  addition  of  lumpy  spheres 
and  rude  dumb-bells  of  urate  of  ammonia  (see  Fig.  3).  This 
deposit  has  a  strong  tendency  to  aggregate  into  masses  or  con- 
cretions; the  urine  has  an  ammoniacal  and  often  an  offensive 


REACTION    OF    THE    UK7NK.  83 

putrescent  odor;  it  is  highly  irritating  to  tli<;  uiucou.s  rnoni- 
branes,  and  excites  inilammation  of  them  if  the  conlact  ix;  lony; 
continued. 

A  urine  alkaline  from  fixed  alkali  ([)otaHh  or  sodaj  reflects  a 
state  of  the  blood;  a  urine  alkaline  from  ammonia  (if  alkaline 
when  voided)  points  to  a  local  affection  of  some  part  of  the 
lower  urinary  passages.  This  latter  statement  is,  however,  not 
to  be  taken  altogether  without  ({ualification.  In  two  instances 
(both  cases  of  advanced  Bright's  disease)  I  have  observed  the 
urine  to  be  ammoniacal  as  it  flowed  from  the  l)ladder  without 
any  clinical  or  post-mortem  sign  of  inflammation  of  any  part  of 
the  urinary  passages,  or  any  evidence  of  such  delay  in  the 
evacuation  of  the  urine  as  might  determine  decomposition  of  it 
in  the  bladder.  One  of  these  cases  is  referred  to  hereafter  {see 
Bright's  Disease).  Dr.  Graves  {Clin.  Leds.,  1,  p.  272)  gives  also 
two  cases,  one  of  continued  fever,  and  the  other  of  anasarca  and 
ascites,  in  which  the  fresh  urine  contained  large  quantities  of 
carbonate  of  ammonia  without  the  least  evidence  of  decomposi- 
tion after  secretion. 

The  transformation  of  urea  into  carbonate  of  ammonia  is  easily 
explained.  One  molecule  of  urea  combines  with  two  molecules 
of  water  to  form  one  molecule  of  carbonate  of  ammonia: 

CO(NH,),  +  2H,0  =  (NHJ,C03 
or 

C0^g^  +  2H,0=.C0.gg;g 

It  is  now  well  established  that  the  production  of  ammoniacal 
urine  is  an  example  of  bacterial  fermentation.  Pasteur  showed 
that  urea  was  changed  into  carbonate  of  ammonia  by  the  action 
of  a  minute  micrococcus — to  which  Cohn  subsequently  gave  the 
name  of  Micrococcus  urece.  The  power  of  decomposed  organic 
matter  and  of  stale  urine  to  bring  about  this  change  with  celerity 
is  simply  due  to  the  fact  that  these  decomposing  materials  are 
highly  charged  with  bacteria  of  various  kinds.  It  is  not  at  all 
probable  that  Pasteur's  micrococcus  is  the  only  organism  which 
acts  as  a  urea-ferment.  There  are,  in  all  likelihood,  other  bac- 
teria capable  of  breaking  up  urea  into  carbonate  of  ammonia — 
though  not,  perhaps,  with  the  same  rapidity  as  the  M.  urese. 
This  subject  will  come  under  notice  again  in  the  section  on 
Microorganisms  in  the  Urine  (Chapt.  iv.  Sect.  ix.). 

If  the  urine  be  ammoniacal  lolwi  voided,  this  is  nearly  always 
associated  with  inflammation  of  some  part  of  the  urinary  mucous 
membrane — generally  that  of  the  bladder.  Any  condition  which 
interferes  with  the  complete  emptying  of  the  bladder  in  mictu- 
rition favors  the  production  of  ammoniacal  urine.     Consequently, 


84  PHYSICAL    PROPERTIES    OF    THE    URINE, 

injuries  to  the  spine  determining  paraplegia  with  paralysis  of  the 
bladder,  obstinate  urethral  stricture,  enlarged  prostate,  calculous 
concretions,  morbid  growths  of  foreign  bodies  in  the  bladder,  are 
sooner  or  later  complicated  with  ammoniacal  urine.  A  very  dis- 
tressing and  intractable  state  of  things  is  thus  brought  about. 
The  ammoniacal  urine  irritates  the  mucous  membrane  and  in- 
duces cystitis;  and  the  purulent  secretion  thus  engendered 
reacts  on  the  urine  and  favors  its  decomposition.  The  two  con- 
ditions naturally  aggravate  each  other  and  perpetuate  each 
other's  existence  after  the  original  cause  has  passed  away. 
Cystitis  may,  in  this  way,  persist  for  years  after  the  removal  of 
a  stone,  or  the  cure  of  a  stricture,  which  was  its  original  cause. 

Dr.  Owen  Rees  believes  that  the  urine  is  sometimes  alkaline 
from  the  secretion  of  an  alkaline  mucus  by  the  mucous  mem- 
brane of  the  bladder.  When  the  membrane  is  irritated  or  in- 
flamed, as  in  paraplegia  from  spinal  injuries,  extroversion  of 
the  bladder,  etc.,  the  irritated  membrane  pours  out,  as  he  be- 
lieves, so  much  alkaline  mucus  that  the  reaction  of  the  urine 
is  changed  thereby.  Dr.  Rees  fortifies  this  hypothesis  by  an 
observation  which  he  made  on  a  case  of  extroverted  bladder. 
He  says :  "As  is  usually  the  case  in  such  persons,  the  anterior 
portion  of  the  bladder  was  wanting ;  so  that  the  fundus  of  that 
viscus  covered  by  mucous  membrane  was  projected  forward 
where  the  abdominal  walls  were  deficient.  The  openings  of  the 
ureters  were  thus  presented  to  view.  The  mucous  membrane 
was  red  and  inflamed  from  exposure,  and  an  alkaline  fluid  was 
constantly  discharging  from  its  surface.  To  what  this  alkaline 
flux  amounted  during  the  day  it  was,  of  course,  impossible  to 
ascertain ;  but  it  was  more  than  suflicient  to  destroy  the  acidity 
of  the  urine,  which  was  quite  alkaline  after  flowing  over  the 
membrane.  Thus  a  piece  of  blue  litmus  was  applied  to  the 
openings  of  the  ureters,  so  as  to  test  the  urine  immediately  it 
flowed  from  them :  the  paper  was  reddened,  indicating  that 
the  urine  was  secreted  of  its  natural  character,  and  with  its 
full  amount  of  acidity.  When,  however,  the  litmus  paper  was 
applied  about  a  quarter  of  an  inch  below  the  opening,  so  as  to 
test  the  urine  after  it  had  passed  over  that  short  distance  of 
mucous  surface,  its  character  was  quite  changed:  it  no  longer 
reddened  the  blue  litmus  paper,  but  on  the  contrary  was  suf- 
ficiently alkaline  to  restore  the  blue  color  to  those  parts  of  the 
paper  which  had  been  previously  reddened  by  exposure  to  the 
urine  as  it  escaped  fresh  from  the  ureters."^ 

An  opportunity  occurred  to  me  of  repeating  this  observation 
on  a  patient  with  extroversion  of  the  bladder;  but  I  was  not 
able  to  satisfy  myself  that  the  alkalinity  of  the  exposed  mucous 

1  Lettsomain  Lectures,  Med.  Times  and  Gaz.,  1851. 


REACTION    OF    THE    URINE.  85 

membrane  was  not  owing  to  blood-serum  or  lymph  wliicb  oozod 
from  the  raw  excoriated  surface,  rather  than  to  any  mucous 
secretion  such  as  might  be  yielded  by  a  merely  inflamed  mucous 
membrane. 

The  therapeutical  indications  in  cases  of  ammoniacal  urine 
from  decomposition  within  the  bladder,  are  clear  enough.  The 
first  object  is  to  remove,  if  possible,  the  impediment  to  the  com- 
plete emptying  of  the  viscus.  In  the  case  of  a  stone  or  foreign 
body  in  the  bladder,  and  in  stricture,  this  is  within  reach  of 
surgical  operation.  If  the  cause  be  irremovable,  or  if  the  am- 
moniacal urine  and  cystitis  persist  after  the  removal  of  the 
original  cause,  all  our  efforts  must  be  directed  to  prevent  the 
sojourn  in  the  bladder  of  the  stale  remnants  of  urine  after 
micturition;  this  can  be  best  effected  by  completely  emptying 
the  bladder  two,  three,  or  four  times  daily  with  an  elastic 
catheter,  which  the  patient  may  be  taught  to  introduce  for  him- 
self. The  bladder  should  also  be  washed  out  once  or  twice  a 
day  with  an  antiseptic  solution — such  as  a  saturated  solution  of 
boracic  acid,  or  a  weak  dilution  of  carbolic  acid.  There  is, 
however,  another  mode  of  washing  out  the  bladder,  which  I 
have  several  times  resorted  to  with  advantage  in  a  certain  class 
of  cases,  more  particularly  in  those  in  which  chronic  cystitis  is 
kept  up  by  the  ammoniacal  state  of  the  urine,  after  the  original 
cause  has  been  removed.  In  these  cases  the  patients  are  made 
to  drink  large  quantities  of  water  at  regulated  intervals.  An 
abundant  flow  of  very  dilute  urine  is  thereby  kept  up  which 
effectually  washes  out  the  bladder  and  gradually  restores  the 
urine  to  its  natural  state. 


CHAPTEE   III. 

CHEMICAL  CONSTITUENTS  OF  THE  URINE  AND  THEIR 
VARIATIONS— INORGANIC  DEPOSITS. 

I.— PKELIMINAEY   EEMAEKS   ON   UKINARY   DEPOSITS   AND 
THEIK  CLASSIFICATION. 

A  VERY  scanty,  light,  cloudy  deposit  is  natural  even  to  the 
healthy  urine  after  standing  some  hours.  This  usually  sinks  to 
the  bottom ;  but  occasionally  it  floats  like  a  cloud  about  the 
middle  or  near  the  surface.  It  is  composed  of  epithelial  scales 
(or  remnants  of  them)  from  the*  mucous  surfaces  of  the  bladder 
and  urethra,  and  pelvis  of  the  kidney.  Of  mucus,  having  the 
usual  glairy  character,  there  is  no  visible  trace  in  perfectly 
healthy  urine. 

Under  a  variety  of  unnatural  circumstances  more  abundant 
deposits  or  sediments  occur  in  urine;  and  a  knowledge  of  their 
nature  sometimes  yields  most  important  practical  information. 

Urinary  deposits  are  arranged  in  two  divisions — Inorganic  and 
Organic. 

Inorganic  deposits  include  substances  which,  for  the  most  part, 
exist  naturally  in  the  urine  in  a  soluble  state;  but  which,  owing 
to  their  excessive  quantity,  or  a  change  of  reaction  in  the  urine, 
or  some  other  circumstance,  are  rendered  insoluble,  and  thereby 
precipitated  in  a  crystalline  or  amorphous  condition.  This 
division  contains:  Uric  acid,  the  amorphous  urates,  urates  of 
ammonia  and  soda,  oxalate  of  lime,  ammoniacal  and  earthy 
phosphates,  carbonate  of  lime,  cystine,  leucine,  and  tyrosine. 
All  these  are  soluble  in  mineral  acids  or  in  alkalies,  and  one  of 
them  (the  amorphous  urate)  by  simply  warming  the  urine. 

Organic  deposits  embrace  all  those  organic  forms,  of  which 
the  presence  alone  in  urine  is  suificient,  from  their  insolubility, 
to  determine  their  subsidence.  They  do  not  belong  in  any  pro- 
portion to  the  healthy  secretion;  and  whenever  present,  they 
are  merely  suspended  in  it;  so  that  when  the  urine  is  left  at 
rest,  they  gravitate  to  the  bottom  and  form  a  sediment.  This 
group  includes  epithelial  cells  from  the  uriniferous  tubes  or 
from  any  part  of  the  genito-urinary  passages,  casts  or  moulds 
(composed  of  a  fibrinous  matter)  of  the  uriniferous  tubes,  oily 
particles,  pus,  blood,  cancerous  and  tuberculous  debris,  sperma- 


URIO    ACID. 


87 


tozoa,  and  bacteria.     All  these  are  insolublem  acid.s  and  alkalies 
as  applied  in  the  ordinary  examination  of  the  urine. 

II.— URIC  ACID,  CjIIiN/V 
{Synonym — Litldc  acid. ) 

Uric  acid  exists  in  normal  urine  in  combination  with  alkaline 
bases;  but  under  certain  conditions  it  is  precipitated  in  the  free 
state,  and  forms  a  deposit  of  orange-red  crystals. 

Naked-eye  Characteks. — The  crystalline  nature  of  the  deposit 
can  nearly  always  be  recognized  by  the  naked  eye ;  but  in  rare 
instances  the  crystals  are  so  small  that  they  require  the  micro- 
scope for  their  detection.  Uric  acid  crystals  may  form  a  lilm  on 
the  surface,  or  lie  scattered  as  brilliant  brown  specks  on  the 
sides  of  the  glass,  or  subside  into  a  dense  red  deposit  like  cayenne 
pepper.  The  naked  eye  is  nearly  always  sufficient  to  identify 
uric  acid  with,  certainty,  because  no  other  brown  crystals  occur  in 
urine  as  a  spontaneous  deposit.  When  the  crystals  are  very 
minute,  the  deposit  resembles  the  amorphous  urate,  but  is  denser, 
and  sinks  more  rapidly.  Urine  depositing  uric  acid  has  com- 
monly a  rich  yellow  or  orange  color,  and  is  invariably  acid. 

Micro-chemical  Characters. — The  primary  form  of  uric 
acid  is  a  rhombic  prism  or  lozenge,  and  to  some  modification  of 

Fig.  4. 


The  simpler  forms  of  uric  acid  crj'stals — quadrangular  and  oval  tablets,  cubes,  six-sided  tablets,  lozenge 

and  barrel-shaped  figures. 

this  figure  the  protean  diversities  of  uric  acid  crystals  mar  all 
be  referred.     The  angles  of  the  crystals  are  sometimes  almost 


88 


CHEMICAL    CONSTITUENTS    OF    THE    URINE, 


equal,  and  then  quadrangular  tables  or  almost  perfect  cubes  are 
obtained  (Fig.  4,  a  b). 

More  frequently  the  angles  are  rounded  oif  (c  d)  so  as^  to  pro- 
duce ovoid s  and  barrel  shapes.  A  still  greater  elongation  pro- 
duces a  rod,  and  when  a  number  of  these  are  joined  together 
in  a  common  centre,  stars  are  produced.     The  beauty  and  end- 

FiG.  5. 


stars  of  uric  acid. 


less  variety  of  these  stars  are  marvellous,  and  render  them 
seductive  microscopic  objects  (Figs.  5  and  6). 

Sometimes  the  rays  extend  only  in  one  direction,  and  a  fan- 
shaped  figure  is  produced,  or  two  fans  are  joined  in  a  common 
centre  (Fig.  6). 

Among  the  less  common  varieties  may  be  mentioned  pointed, 
solid-looking  crystals,  with  a  dark  shading  at  either  end 
(Fig.  7,  a).  When  these  lie  flat,  they  have  a  totally  different 
appearance,  and  resemble  prisms  of  the  triple  phosphate  {h  b). 
Other  forms  are  halbert-shaped  (c),  six-sided  tablets  (Fig.  4,  e), 
etc.  The  most  curious  and  varied  forms  of  uric  acid  are  gen- 
erally found  in  albuminous  urines.^ 

Uric  acid  is  excessively  insoluble.  It  requires  1800  parts  of 
boiling  water  and  15,000  parts  of  cold  water  for  solution.     It  is 

^  Some  interesting  details  on  the  varying  forms  of  uric  acid  crystals  and  the 
conditions  under  which  they  appear  may  be  found  in  a  paper  by  Dr.  Wm.  Ord, 
St.  Thos.  Hosp.  Kep.,  1870,  p.  335.  Dr.  Ord  returns  to  this  subject,  and  gives 
some  additional  information  in  a  paper  in  the  Med.  Chir.  Trans.,  1875.  See  also 
his  work,  "On  the  Influence  of  Colloids  upon  Crystalline  Form  and  Cohesion." 
Lond.,  1879. 


URIC    ACID. 


89 


insoluble  in  all  dilute  acids,  hut  is  decomposed  with  efferves- 
cence by  strong  nitric  acid.     Caustic  alkalies  dissolve  it  readily, 


Fig.  6. 


Stars  aud  spikes  of  uric  acid. 


especially  with  the  aid  of  heat.     It  dissolves  also  freely  in  weak 
solutions  of  the  carbonates  of  lithia,  potash,  and  soda,  and  in 


EiG.  7. 


Karer  forms  of  uric  acid  crystals. 


solutions  of  borax  and  common  phosphate  of  soda.     It  is  in- 
soluble in  alcohol  and  ether.     It  is  entirely  dissipated  by  a  red 


90  CHEMICAL    CONSTITUENTS    OF    THE    UEINE. 

heat.  The  most  delicate  mode  of  recognizing  uric  acid  is  by 
the  murexid  test.  This  is  performed  by  taking  a  small  quantity 
of  the  suspected  substance  and  placing  it  on  a  porcelain  dish  or 
a  slip  of  glass;  a  couple  of  drops  of  strong  nitric  acid  are  then 
added,  and  the  heat  of  the  spirit-lamp  applied;  the  uric  acid 
dissolves  with  eifervescence;  the  heat  is  continued  until  the 
liquid  dries  into  a  yellowish-red  residue.  If  the  residue,  when 
cool,  is  touched  with  a  rod  dipped  in  caustic  ammonia,  a  bright 
violet-blue  (murexid)  is  instantly  developed,  which  is  perfectly 
characteristic. 

Quantitative  determinations  of  uric  acid  in  urine  are  generally 
made  by  adding  excess  of  acetic  or  muriatic  acid  to  a  known 
quantity  of  the  urine,  and  allowing  it  to  stand  for  twenty-four 
hours  to  precipitate.  The  acid  is  thrown  down  in  a  crystalline 
form,  and  may  be  collected  either  by  decantation  and  levigation, 
or  on  a  weighed  filter ;  it  is  then  dried  and  weighed.  The  Rev. 
W.  Yernon  Harcourt,  in  a  long  series  of  observations,  has  shown 
that  the  above  process  is  liable  to  very  great  errors,  even  when 
the  urine  has  been  previously  concentrated  by  evaporation.  He 
obtained  much  more  accurate  results  by  the  following  method : 
ISTeutralize  a  third  or  fourth  part  of  the  urine  of  twenty-four 
hours,  if  alkaline  with  hydrochloric  acid,  or  if  acid  with  car- 
bonate of  potash ;  reduce  this  to  IJ  fluidounce  by  evaporation ; 
treat  this  with  3  drachms  of  hydrochloric  acid  combined  with 
1 J  ounce  of  alcohol ;  decant  when  the  uric  acid  has  been  pre- 
cipitated and  the  liquid  is  clear;  wash  the  deposit  on  a  weighed 
filter  first  with  alcohol,  and  when  that  dissolves  no  more,  with 
equal  parts  of  acetic  acid  and  water;  lastly,  dry  the  filter  and 
weigh. ^ 

Dr.  Pavy^  estimates  uric  acid  by  making  use  of  its  reducing 
action  on  ammoniated  solution  of  sulphate  of  copper  (see  Sugar). 
The  total  reducing  power  of  the  urine  is  first  determined,  and 
then  the  uric  acid  is  precipitated  by  acetate  of  lead.  The  re- 
ducing power  is  then  again  determined,  and  the  difierence  of 
the  two  determinations  gives  the  reducing  power  of  the  uric 
acid  present. 

Mr.  Cook  finds  it  difficult  to  decide  the  determining  point  in 
the  above  method.  He  recommends  the  following  process  :  To 
the  alkalized  urine,  add  a  solution  of  sulphate  of  zinc,  and  col- 
lect the  precipitate  of  urate  of  zinc  which  forms.  Thoroughly 
wash  the  precipitate  with  saturated  solution  of  urate  of  zinc,  in 
order  to  remove  urea  and  ammonia.  The  filter  paper  contain- 
ing the  precipitate  may  then  be  placed  in  a  urea-estimation  ap- 
paratus, and  treated  with  hypobromite  of  sodium.     The  urate 

1  Med.  Times  and  Gaz.,  1869,  vol.  ii.  p.  482. 
^  Med.  Chip.  Trans.,  vol.  Ixiii. 


URIC    AC  J  D.  91 

of  zinc  is  decomposed,  and  the  uric  acid  may  he  estimated  hy  the 
amount  of  nitrogen  given  off. 

(For  details,  see  Brit.  Med.  Journ.,  April,  1882.) 
Origin  and  Occurrence. — The  quantity  of  uric  acid  in  the 
urine  is  very  minute;  and  were  it  not  for  its  sparing  solubility 
and  liability  to  he  precipitated  both  before  and  after  emission, 
its  clinical  significance  would  be  very  slight.  The  daily  excretion 
of  uric  acid  amounts  to  no  more  than  8  or  10  grains.  Indi- 
viduals vary  a  good  deal  in  the  amounts  which  they  habitually 
separate.  In  three  healthy  young  students  living  on  a  similar 
diet  and  under  similar  circumstances,  I  found  the  following 
numbers: 


No.  I  (mean  of  47  clays) 8.051  grains. 

"    2  (mean  of    5  days)       .......     3.462       " 

"    3  (mean  of    3  days) G.071       " 

Dr.  Hammond  found  in  his  own  case  the  daily  average  as 
high  as  14.14  grains. 

The  excretion  of  uric  acid  also  presents  considerable  varia- 
tions in  the  same  individual  from  day  to  day.  The  greatest 
oscillation  of  this  sort  observed  by  myself  amounted  to  a  difler- 
ence  of  more  than  one-half  on  two  successive  days:  on  the  first 
day  5.45  grains  were  separated,  and  on  the  following  day  11.7 
grains.  It  was  found  that  when  the  mode  of  life  was  tolerably 
uniform,  the  amounts  separated  in  periods  of  five  consecutive 
days  varied  only  slightly  from  each  other  in  the  same  individual. 

The  occurrence  of  a  spontaneous  deposit  of  uric  acid  is  by  no 
means  a  sure  indication  of  an  increased  excretion ;  and  I  fre- 
quently found  that  those  days  on  which  a  spontaneous  deposit 
occurred,  showed  less  uric  acid  tha^n  those  days  on  which  no 
uric  acid  was  spontaneously  deposited.  The  mean  daily  quan- 
tity of  uric  acid  separated  in  twelve  days  on  which  there  was  a 
deposit  was  7.7  grains;  and  the  mean  of  twenty-five  other  days 
on  which  no  uric  acid  was  spontaneously  deposited  was  7.3 
grains. 

The  digestion  of  food  has  a  marked  effect  on  the  excretion  of 
uric  acid.  I  found  it  increased  after  eating,  not  only  absolutely, 
but  also  relatively  to  the  other  solid  matters  of  the  urine.  In 
the  following  table  the  results  of  seven  days'  ohservations  on 
the  effect  of  dinner  are  exhibited.  Three  periods  are  chosen 
for  comparison,  namely:  1,  during  the  prevalence  of  the  alka- 
line tide  which  corresponds  with  the  passage  of  the  digested 
food  into  the  blood;  2,  during  the  subsequent  period  in  Avhich 
the  acid  of  the  urine  is  restored,  but  the  effect  of  the  meal  still 
continues  to  be  perceptible  in  the  considerable  quantity  of  solid 


92 


CHEMICAL    CONSTITUENTS    OF    THE    URINE, 


matters  separated  by  the  kidneys;^  and,  3,  during  sleep,  which 
is  also  a  time  of  fasting. 


Time  of  day. 

(Dinner  at  2  p.m.) 


4-  7  P.M.,  alkaline  tide. 
9-11     "      acidity  restored. 
1—  7  a.m.,  urine  of  sleep. 


Uric  acid,  per  1000 

grains  of  liquid 

urine. 


0.40  grain. 
0.18      " 
0.39      " 


Uric  acid  per  hour. 


0.36  grain. 
0.13      " 
0.10      " 


Uric  acid,  per  lou 

grains  of  solid 

urine. 


0.83  grain. 
0.34      " 
0.60      " 


It  is  seen  that  the  absolute  quantity  hourly  secreted  is  three 
times  greater  during  the  period  of  the  alkaline  tide  than  during 
the  other  periods ;  its  proportion  to  the  total  solids  is  also  very 
sensibly  greater.  Even  its  proportion  to  the  water  of  the  urine 
is  greater  than  at  any  other  period,  though  the  urine  of  sleep 
generally  (under  the  mode  of  life  then  followed)  deposited  amor- 
phous urates  very  copiously  after  standing  a  few  hours,  whereas 
the  urine  of  the  alkaline  tide  never  deposited  urates.^  It  is 
further  seen  from  the  table  that  the  amount  of  uric  acid  has  no 
relation  to  the  degree  of  acidity  of  the  urine. 

Professor  Ranke  has  shown  that  neither  sex  nor  age,  nor  the 
height  and  weight  of  the  body,  have  an^^  decided  relation  to  the 
daily  excretion  of  uric  acid.^  The  season  of  the  year,  and  the 
animal  or  vegetable  nature  of  the  food,  have  little  influence, 
provided  the  articles  of  diet  are  equally  rich  in  nitrogen.  The 
effect  of  exercise  is  uncertain;  sometimes  it  increases,  sometimes 
it  diminishes  the  uric  acid.* 

Pathologically,  it  is  found  that  the  daily  excretion  of  uric  acid 
is  markedl}^  increased  in  the  febrile  state,  in  certain  diseases  of 
the  liver,  in  strumous  and  tubercular  subjects,  in  rickets,  scurvy, 
and  leukaemia,  and  after  an  attack  of  gout.  On  the  other  hand, 
it  is  diminished  during  the  paroxysm  of  gout,  and,  according  to 
Ranke,  after  large  doses  of  quinine. 

Uric  acid  is  nearly  related,  both  chemically  and  physiologi- 
cally, to  urea.  Uric  acid  yields  urea  as  one  of  the  products  of 
its  decomposition,  both  by  artificial  means  in  the  laboratory  and 
within  the  animal  body.  ISTevertheless,  the  most  exact  observa- 
tions have  failed  to  show  that  there  is  any  inverse  correspond- 
ence between  the  excretion  of  the  two  substances;  usually  urea 
and  uric  acid  increase  and  diminish  together. 

Clinical  Significance  of  Ukic  Acid. — From  what  has  been 
already  stated,  it  will  be  readily  conceived  that  the  clinical  in- 

1  See  Table,  p.  52. 

^  The  seven  days'  experiments  here  spoken  of  are  the  same  seven  days  which  are 
tabulated  at  p.  52. 

^  Kanke,  Ausscheidung  d.  Harnsaure  beim  Menschen,  Munich,  1858. 
*  See  Parkes,  on  the  Composition  of  the  Urine,"'p.  88. 


URIC    AG11>.  03 

terest  of  uric  acid  in  the  uriiio  lia.s  not  ko  much  to  do  witli  the 
variations  of  its  quantity,  wliother  absolute  or  rehitivo,  as  witli 
its  precipitation  in  the  free  state,  and  the  time  and  place  of  that 
precipitation.  The  circumstances  favoral^le  to  the  preci[)itation 
of  free  uric  acid  are,  an  acid  reaction  of  the  urine,  and  abeyance 
of  the  conditions  which  determine  the  precipitation  of  uric  acid 
in  combination  (amorphous  urates);  these  latter  are  considered 
in  the  next  section. 

A  deposit  of  uric  acid  occurring  some  twelve  or  twenty  hours 
after  emission  has  no  pathological  signification.  IlealtJjy  acid 
urines  usually  deposit  uric  acid  as  a  normal  event  on  long  stand- 
ing. If  the  deposit  take  place  within  three  or  four  hours  after 
emission,  the  circumstance  is  certainly  not  natural;  but  it  is  not 
one  requiring  special  therapeutical  attention;  it  is  frequently 
observed  in  convalescence  from  febrile  complaints,  especially 
articular  rheumatism;  also  in  the  middle  periods  of  chronic 
Bright's  disease,  in  chorea,  in  certain  types  of  diabetes,  and  in 
enlargements  of  the  spleen. 

But  if  uric  acid  be  precipitated  before  the  urine  cools,  or  im- 
mediately after,  it  cannot  fail  to  awaken  apprehensions  that  a 
similar  event  may  take  place  within  some  part  of  the  urinary 
passages,  and  give  rise  to  the  formation  of  gravel  and  calculi, 
with  all  their  train  of  painful  and  dangerous  consequences.  A 
prophylactic  treatment  is  urgently  called  for  under  such  circum- 
stances, by  which  this  danger  may  be  warded  ofi".  But  it  will 
be  more  convenient  to  postpone  the  further  consideration  of  this 
important  subject  to  the  sections  which  are  specially  devoted  to 
the  pathology  and  treatment  of  calculous  disorders. 

The  relation  of  uric  acid  to  the  pathology  of  gout  has  been 
studied  with  great  success  by  Dr.  Garrod.  He  has  proved  that 
the  blood  of  a  gouty  patient  is  permanently  surcharged  with 
uric  acid,  and  that  the  acid  is  deposited  in  combination  with 
soda  in  the  cartilaginous  and  fibrous  tissues  of  the  joints,  and 
becomes  the  cause  of  the  articular  inflammations  which  are 
characteristic  of  gout.  This  unnatural  accumulation  appears  to 
be  due  to  a  defective  power  of  eliminating  uric  acid  in  the  kid- 
neys. The  kidneys  themselves  also  suffer — their  secreting 
tubules  and  the  intertubular  substance  are  clogged  with  urate 
deposits,  and  the  foundation  is  laid  of  those  atrophic  changes 
which  constitute  one  of  the  most  fatal  forms  of  chronic  Bright's 
Disease.  It  maj^  be  regarded  as  probable  that  the  defective 
power  of  the  kiclneys  to  eliminate  uric  acid  in  gout  arises  from 
a  diminished  alkalescence  of  the  blood,  and  that  the  rational 
correction  of  this  defect  is,  in  addition  to  a  revision  of  the  diet- 
ary, a  steady  exhibition  of  the  carbonates  of  lithia  or  potash  in 
the  intervals  of  the  articular  paroxysms. 


94 


CHEMICAL    CONSTITUENTS    OF    THE    URINE, 


III.— AMOKPHOUS  URATES. 

[Synonyms^^amorphous  lithates ;  urate  of  ammonia  of  Prout  and  Bird ;  urate 
of  soda  of  Heintz  and  Lehmarin;  lateritious  deposit.) 

]S"aked-eye  Characters. — The  "  amorphous  urate  "''  usually 
occurs  as  a  loose,  reddish,  pulverulent  deposit  wholly  devoid  of 
crystallization.  Its  color  is  always  deeper  than  the  urine  from 
which  it  falls ;  but  the  color  varies  extremely  both  in  intensity 
and  tint.  It  may  be  fawn,  orange,  brick-red,  pink,  or  purplish. 
It  commonly  sinks  soon  and  completely ;  more  rarely,  especially 
in  albuminous  urines,  the  precipitate  continues  a  long  while 
diffused  in  the  urine,  giving  it  a  milky  appearance.  If  the  pre- 
cipitation take  place  after  the  urine  has  been  at  rest  in  the  urine 
glass,  a  film  or  bloom  forms  on  the  surface  and  sides,  which  is 
readily  seen  by  inclining  the  glass  to  one  side.  By  this  pecu- 
liarity the  amorphous  urates  may  be  distinguished  from  all  other 
urinary  deposits  by  the  unaided  senses. 

MiCRO-CHEMiCAL  CHARACTERS. — Under  the  microscope  the  de- 
posit is  found  to  be  composed  of  minute  particles  or  granules, 
coarser  or  finer,  and  more  or  less  opaque,  according  to  the  close- 
ness of  its  aggregation  (see  Fig.  8). 

Fig.  8. 


Amorphous  urate  deposit. 

By  warming  the  urine,  the  amorphous  urate  dissolves ;  the 
light-colored  and  looser  deposits  disappear  with  a  slight  heat, 
but  the  deeper  colored  and  denser  ones  require  a  more  elevated 
temperature.  As  no  other  urinary  deposit  disappears  with 
simple  heat,  this  circumstance  offers  an  easy  means  of  recog- 
nition. The  amorphous  urate  answers  to  the  murexid  test  for 
uric  acid.     It  is  decomposed  by  the  vegetable  and  mineral  acids 


A  M  O  R  r  H  O  U  H    U  li  A  T  E  S .  95 

(though  only  slowly  in  the  cold  by  the  former),  and  uric  acid 
crystals  are  deposited,  which  iriay  be  recognized  under  the  riiicro- 
scope.  The  urates  dissolve  in  the  caustic  alkalies,  and  in  solu- 
tions of  the  alkaline  carbonates.  They  possess  an  intense  afKnity 
for  the  brown  and  pink  pigments  of  the  urine,  which  they  carry 
down  with  them  when  precipitated ;  and  the  varied  tints  which 
they  present  as  deposits  depend  on  this  circumstance. 

The  chemical  composition  of  this  de])Osit  has  been  a  sul)ject 
of  much  dispute.  Prout  and  Bird  believed  it  to  be  com[)Osed 
of  urate  of  ammonia,  and  it  usually  passes  under  that  name  in 
this  country.  In  Germany  it  is  commonly  considered  to  be 
mainly  composed  of  urate  of  soda.  More  recent  observations 
indicate  that  neither  of  these  views  is  correct ;  it  would  appear 
rather  that  the  amorphous  urates  have  not  a  fixed  and  constant 
composition,  but  vary  considerably  in  dififerent  samples.  In  all, 
however,  uric  acid  is  combined  with  several  bases — potash,  soda, 
ammonia,  and  lime ;  and  this  is  the  special  chemical  character- 
istic of  the  deposit,  that  it  is  composed  of  mixed  urates.  Some- 
times one  base  and  sometimes  another  preponderates.  The 
proportion  of  uric  acid  in  the  deposit  is  very  large,  but  not  con- 
stant. Scherer  found  a  little  over  80  per  cent. ;  Dr.  Bence  Jones 
over  90  per  cent.  This  proportion  is  about  twice  as  much  as  is 
necessary  to  form  acid  urates  (biurates)  with  the  bases  present: 
so  that  about  one-half  of  the  uric  acid  is  loosely  united  Avith  the 
biurates  to  form  the  deposit,  which,  therefore,  resembles  in  its 
chemical  constitution  the  quadroxalate  of  potash.  The  loosely 
combined  uric  acid  can  be  separated  from  the  associated  biurates 
by  simply  treating  the  deposit  with  warm  water,  or  by  repeatedly 
washing  it  on  a  filter  with  cold  water. 

Dr.  B.  Jones  found  potash  the  most  abundant  base,  next 
ammonia,  and  last  soda,  as  the  following  table  of  his  analyses 
shows : ' 

First  analysis.  Second  analysis. 

Uric  acid 94.36  91.06 

Potassium 3.15  3.78 

Ammonium        .         .         .         .         .         .         .1.36  3.36 

Sodium 1.11  1.87 

Hassall  and  Scherer  always  found  lime  in  not  inconsiderable 
quantity.  Dr.  Bence  Jones  succeeded  in  producing  artificiallv 
exact  counterparts  of  the  amorphous  urates  both  with  potash 
and  soda. 

The  precipitation  of  the  amorphous  urates  depends  on  a  con- 
junction of  the  following  conditions :  an  acid  reaction,  low 
temperature,  and  concentration  of  tb£  urine.     The  occurrence 

^  See  a  paper  by  Dr.  Bence  Jones  in  the  Journal  of  the  Chemical  Society, 
June,  1862. 


96  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

of  this  deposit  is  a  sure  sign  of  an  acid  reaction ;  and  the  more 
acid  the  urine,  the  more  liable  is  it  to  deposit  the  amorphous 
urates:  A  drop  of  acetic  or  nitric  acid  will  frequently  deter- 
mine at  once  the  precipitation  of  the  amorphous  urates  in  a 
previously  clear  urine.  The  effect  of  temperature  is  very 
marked :  and  on  cold  winter  mornings  the  urine  voided  on 
getting  out  of  bed  generally  becomes  turbid  from  precipitated 
urates  a  few  hours  after. 

The  amorphous  urate  deposit  is  not  a  sign  of  excessive  secre- 
tion of  uric  acid  by  the  kidneys ;  it  indicates  rather,  that  its 
proportion  to  the  water  of  the  urine  is  excessive.  Urines  of  a 
high  density,  provided  their  reaction  be  acid  and  the  tempera- 
ture low,  usually  deposit  urates  in  healthy  persons.  There  is 
this  difference  between  the  conditions  favorable  to  the  deposit 
of  free  uric  acid  and  of  the  amorphous  urates — that  a  high 
density  or  (concentration)  favors  the  latter,  and  a  low  density 
(or  dilution)  favors  the  former.  On  a  comparison  of  the  densi- 
ties of  a  large  number  of  urines,  depositing  respectively  amor- 
phous urates  and  free  uric  acid,  I  found  the  mean  sp.  gr.  of 
the  former  1027,  and  of  the  latter  1021.  It  is  familiarly  observed 
that  a  urine  which  throws  down  urates,  will  begin  to  deposit 
free  uric  acid  a  few  hours  after,  when  it  has  become,  quoad  uric 
acid,  less  concentrated. 

The  clinical  significance  of  a  urate  deposit  can  be  appreciated 
only  after  due  consideration  of  the  above  physical  and  chemical 
conditions  of  its  occurrence  in  the  physiological  state.  I  have 
already  stated  that  no  conclusion  as  to  excessive  elimination  of 
uric  acid  can  be  drawn  from  the  occurrence  of  the  urate  deposit. 
It  has  also  been  shown  in  a  previous  page,  that  during  the 
absorption  of  food,  and  the  flow  of  the  alkaline  tide,  the  excre- 
tion of  uric  acid  is  at  its  maximum,  though  the  urine  at  this 
period  very  rarely  deposits  urates,  owing  to  the  depression  or 
disappearance  of  its  acidity :  and  conversely,  that  after  long 
fasting  the  urine  is  very  apt  to  deposit  urates,  because  it  is  then 
concentrated  and  highly  acid,  though  the  hourly  rate  of  excre- 
tion of  uric  acid  is  then  at  its  lowest  ebb. 

A  deposit  of  amorphous  urates  may  be  regarded  as  having 
either  a  physiological  or  a  pathological  signification.  Physio- 
logically, a  urate  deposit  may  be  expected  after  profuse  sweating, 
violent  exercise,  prolonged  abstinence  from  food  and  drink,  and 
in  cold  weather.  Under  these  circumstances  the  deposit  is 
occasional,  and  its  color  usually  fawn  or  brownish.  Pathologically, 
the  most  common  determining  cause  of  the  precipitation  of  the 
amorphous  urates  is  the  febrile  state.  Even  a  slight  degree  of 
pyrexia,  as  in  a  common  cold,  is  usually  accompanied  with  a 
urate  deposit. 

The  frequent  or  constant  occurrence  of  a  brownish  or  red 
urate  deposit  without,  or  with  only  a  feeble  degree  of  pyrexia, 


C  I  i  Y  H  T  A  L  L I N  K    U  K  A  'J^  E  S . 


97 


18  a  circumstance  to  awaken  Hii8])icionH  of  Honio  HeriouB  organic 
disease;  but  the  indication  is  more  general  than  speciaL  Or- 
ganic disease  of  the  lungs,  heart,  liver,  spleen,  or  any  other  part, 
attended  with  emaciation  and  waste  of  the  tissues,  is  usually 
accompanied  with  abundant  deei)-colorcd  urate  deposit. 

Functional  derangements  of  the  digestive  organs  arc  also 
generally  accompanied  by  pale  urate  deposits  in  the  urine. 
Their  occurrence  depends,  in  many  cases  at  least,  as  Dr.  B. 
Jones  has  indicated,  on  a  connection  between  the  reaction  of 
the  mucous  membrane  of  the  stomach  and  that  of  the  urine. 

Treatment. — From  what  has  been  stated  of  the  determining 
conditions  of  the  amorphous  urate  deposit,  it  is  evident  that  it 
seldom  requires  direct  treatment.  Its  indications  are  of  more 
service  in  diagnosis  and  prognosis  than  in  therapeutics.  Some- 
times the  persistence  of  a  urate  deposit  occasions  such  alarm  to 
the  patient  that  it  may  serve  a  good  purpose  to  cause  it  to  dis- 
appear, though  no  really  curative  end  may  be  gained  thereby. 
This  is  easily  and  harmlessly  effected  by  a  few  two-scruple  doses 
of  citrate  of  potash.  When  this  direct  purpose  is  not  aimed  at, 
the  treatment  must  be  directed  to  the  removal  of  the  condition 
causing  the  deposit. 


Fig.  9. 


iy._CEYSTALLINE  UKATES. 

Urate  of  soda  and  urate  of  ammonia  are  sometimes  deposited 
separately  in  urine,  in  the  crystalline  form,  and  under  circum- 
stances wholly  different  from  those  which  determine  the  pre- 
cipitation of  the  amorphous  urates. 

Urate  of  Soda. — Urate  of  soda  is  familiarly  known  as  a  con- 
stituent of  gout}^  concretions.  When  the  point  of  a  lancet  is 
thrust  into  one  of  the  yellowish-white  nodules  so  common  on 
the  ears  of  gouty  persons,  a  whitish 
mortar-like  matter  escapes,  which,  un- 
der the  microscope,  is  resolved  into 
myriads  of  long  delicate  needles,  ar- 
ranged into  bundles  or  stars,  or  lying 
separately  (Fig.  9,  a  «). 

These  acicular  forms  are  never  de- 
posited spontaneously  in  the  urine; 
but  they  may  be  readily  produced  by 
adding  a  little  liquor  sod?e  to  the  com- 
mon amorphous  urate,  in  a  watch-glass, 
and  allowing  the  solution  so  formed  to 
concentrate  by  evaporation  in  the  air 
(Fig.  9,  b  b). 

Urate  of  soda  is  a  comparatively 
rare  spontaneous  deposit  in  urine.     It 

7 


Urate  of  soda. 

a  a.  From  a  gouty  concretion  ;  6  6. 
Artificially  prepared  bj'  adding  liq. . 
sodce  to  the  amorphous  urate  deposit. 


98 


CHEMICAL    CONSTITUENTS    OF    THE    URINE. 


occurs,  however,  occasionally  in  gout,  and  in  the  febrile  state, 
especially  in  children.  It  forms  a  whitish  or  yellow  sediment, 
which" sinks  rapidly;  it  is  associated  with  an  acid  reaction  of  the 
urine,  and  is  frequently,  if  not  generally,  deposited  in  the  bladder 
before  the  emission  of  the  urine.  In  this  respect  it  differs  from 
the  amorphous  urate,  which  is  never  deposited  until  the  urine 
has  cooled. 

Under  the  microscope  the  spontaneous  deposit  of  urate  of  soda 
exhibits  irregular,  opaque,  globular,  and  lumpy  masses,  from 
which  project  spiny  crystals,  sometimes  straight,  sometimes 
variously  curved  [see  Fig,  10). 

The  occurrence  of  this  deposit  in  the  febrile  complaints  of 
infants  and  children  probably  depends  on  the  urine  being  exces- 
sively scanty  and  concentrated  and  long  detained  in  the  bladder. 
Its  appearance  in  such  cases  is  temporary,  and  ceases  on  the 
reestablishment  of  the  flow  of  urine.  The  annexed  drawing 
(Fig.  10)  was  made  from  a  deposit  voided  by  a  little  child  of 
three  years.  The  child  was  suffering  from  severe  infantile  re- 
mittent, and  no  urine  had  been  passed  for  two  days.  While  I 
was  examining  the  abdomen,  the  child  cried,  and  the  urine  began 
to  flow.  The  first  portions  were  turbid  and  of  a  gamboge-yell ov7 
color,  and  contained  the  spiny  masses  here  delineated;  after 
about  an  ounce  of  this  had  come  away,  several  ounces  of  clear 
high-colored  acid  urine  followed. 

Clinically,  this  deposit  derives  its  chief  importance  from  the 
circumstance  that  it  is  precipitated  within  the  urinary  passages. 

The  spiny  crystals  irritate  the  mucous 
Tig.  10.  membrane  of  the  bladder  Or  urethra ; 

and  the  latter  canal  may  even  be 
blocked  up  by  impaction  of  masses  of 
the  deposit.  It  may  also  form  a  nucleus 
around  which  calculous  matter  may 
hereafter  aggregate.  The  great  com- 
parative frequency  of  vesical  calculi  in 
children  is  not  improbably  owing  to 
the  occurrence  of  this  deposit  in  the 
numerous  fugitive  febrile  attacks  to 
which  children  are  subject.'^ 

Urate  of  Ammonia. — When  urine 
becomes  strongly  ammoniacal,  it  is 
liable  to  precipitate  urate  of  ammonia, 
in  addition  to  the  mixed  phosphates  which  are  necessarily 
deposited  under  those  circumstances.     The  urate  of  ammonia 

1  The  correctness  of  this  conjecture  is  fully  borne  out  by  the  researches  of  Dr. 
Vandyke  Carter  on  the  Structure  and  Formation  of  Urinary  Calculi.  He  found 
that  urates  formed  the  chief  part  of  the  nucleus  in  the  majority  of  urinary  calculi. 
(On  the  Microscopic  Structure  of  Urinary  Calculi,  Lond.,  1873.) 


Hedgehog  crystals  of  urate  of  soda, 
spontaneously  deposited  from  the  urine 
of  a  child. 


OXALATE    OF    LIME.  99 

has  usually  a  dense  w)ntc  color;  hut,  I  liave  known  it  j)Osse88  a 
beautiful  violet  hue. 

Two  forms  are  seen  under  the  microscope.     The  most  com- 
mon  are  spheres  and   i^lobular  masses,   which   appear  almost 
black   by  transmitted    light,  owing  tf) 
their   opacity  {see  Fig,  11,  a).     These  Fio.  n. 

spheres  are  easily  obtained  by  leaving  a 
urine  containing  the  amorphous  urate 
to  stand  in  the  air  until  it  becomes 
ammoniacal.  The  second  form  [h)  oc- 
curs as  very  minute  slender  dumb-bells: 

these  generally  lie  singly;    or  two  lie      '^   _    'C'y  "  i^ ^^ 
athwart  each  other  so  as  to  form  a  cross ;  ^  '■-'4,  n  )>>  ^ 

or  three  are  united   so  as  to  form  a  ;,„^.    / 

rosette.       They   become    coarser  "  and  ''      / 

larger  with  long  keeping  of  the  urine.  -^ 

This  deposit  has  no  special  clinical  sig-  i-''">=  "^  ammouia  si-uutuntMmsiy 
niiicance:    its  occurrence  is  merely  an     '^'^p°«"''^i-  «•  spheres  and  giobuiar 

■  '     •  t        ,    ■       ,1  •  11  "^        .         masses;      h.      Bumb-bolls,     crosses, 

incident  in  the  ammoniacal  decoraposi-     rosettes. 
tion    of   the    urine.     It   is   a   frequent 

ingredient  of  the  secondary  phosphatic  crust  which  invests 
urinary  calculi  in  the  later  periods  of  their  growth  (see  Uro- 
lithiasis). 

v.— OXALATE  OF  LIME. 

{^Oxaluria ;  oxalic  acid  diathesis.) 

E"aked-eye  Characters. — A  deposit  of  oxalate  of  lime  is 
usually  very  scanty,  and  looks  like  a  slight  cloud  of  mucus. 
Owing  to  this,  and  its  colorlessness,  it  seldom  attracts  the  atten- 
tion of  a  patient.  If,  however,  the  urine  be  transferred  into  a 
urine-glass  immediately  after  emission,  as  is  usually  practised  in 
hospital  wards,  the  following  appearances  are  produced,  which 
are  sufficiently  characteristic  to  enable  the  observer  to  recognize 
the  deposit  with  certainty  by  the  unaided  eye.  The  sid'es  of 
the  glass  are  seen  to  be  traversed  by  very  numerous  fine  lines, 
running  in  bands,  transverselj'  or  obliquely,  giving  an  appear- 
ance as  if  the  glass  were  finel}^  scratched.  This  appearance  is 
due  to  the  crystallization  of  the  oxalate  011  the  tine  lines  or 
inequalities  left  after  cleaning  the  glass  by  towelling.  The 
subsided  portion  is  equally  peculiar ;  it  consists  of  two  parts — 
a  soft,  pale  gray,  mucous-looking  sediment,  occupying  the  bot- 
tom of  the  vessel,  and  overlying  this  a  snow-white  denser  layer 
with  an  undulating  but  sharply  limited  surface.  The  only  other 
substance  which  crystallizes  in  lines  on  the  sides  of  the  glass  is 
uric  acid;  this  is  easily  discriminated  by  the  greater  coarseness 
of  the  lines  and  their  more  or  less  brown  color. 


100 


CUEMICAL    CONSTITUENTS    OF    THE    URINE, 


Micro-chemical  Characters. — Oxalate  of  lime  occurs  in  very 
minute  crystals,  the  largest  only  appearing  to  the  naked  eye 
as  sparkling  points.  Two  forms  are  met  with.  The  most 
common  are  octahedra,  greatly  shortened,  or  flattened,  in  one 
direction.  The  crystals  present  different  appearances  according 
to  the  side  on  which  they  lie.  Commonly  they  rest  on  their 
short  axis,  and  appear  as  squares  crossed  diagonally  by  a  pair 
of  lines  (Fig.  12,  a).    As  they  roll  over  in  the  lield  of  the  micro- 

Fio.  V2. 


Oxalate  of  lime,     o,  h,  c.  Octahedra  in  "various  positions  ;  d.  Pyramids  ; 
e.  Pyramids  witli  intervening  square  bases. 

scope,  they  assume  various  forms — lengthened,  pointed  octa- 
hedra, crossed  parallelograms,  etc.  (6,  c).  Sometimes  half-crystals 
are  seen — four-sided  pyramids  on  a  square  base  {d);  and  some- 
times two  such  pyramids,  instead  of  being  united  by  their  bases 
to  form  the  ordinary  octahedron,  are  separated  by  a  short  square 
prism  (e).  The  second  form  of  oxalate  of  lime  is  that  of  dumb- 
bells and  minute  ovoids  and  circles  (Fig.  13).  The  different 
appearances  are  produced  by  the  diiferent  postures  assumed  by 
the  objects;  and,  as  they  roll  over  in  the  field  of  the  microscope, 
the  dumb-bell  is  seen  to  change  to  an  ovoid  or  circle,  and  vice 
versa.  Their  real  shape  is  that  of  an  oval  or  circular  disk,  with 
rounded  margins,  and  a  depression  in  the  centre  on  either 
face. 

The  dumb-bells  are  probably  identical  in  composition  with 
the  octahedra.  Dr.  Bird,  in  his  later  editions,  expressed  a  doubt 
on  this  point,  on  the  ground  of  their  different  behavior  with 


O  X  A  I.  A  'J'  E    O  V     L  I  M  E  .  101 

polarized  liglit,'  and  suii^i^cstod  tliat  tlicy  consisted  of  oxalurate 
of  lime.  Sehiuick  has  recently  shown  that  oxalurate  of  ammonia 
may  be  found  in  normal  urine.^  If  this  [)r(>ve  to  be  universally 
true,  it  would  afford  an  easy  explanation  of  the  frequent  occur- 
rence of  oxalate  of  lime  in  urine.     The  precipitation  of  oxalate 

¥w.  13. 


Dumb-bells  and  ovoids  of  oxalate  of  lime. 

of  lime  as  dumb-bells  depends  on  some  physical  condition  which 
interferes  with  the  ordinarj^  crystallization.  Yery  frequently 
urine  depositing  dumb-bells  contains  little  masses  of  viscid 
mucus;  and  it  seems  probable  that  a  certain  viscidity  of  the 
urine  is  essential  to  this  globular  precipitation.^ 

Oxalate  of  lime  is  insoluble  in  alcohol,  ether,  water,  and  the 
vegetable  acids;  but  it  dissolves  readily  in  the  mineral  acids. 
The  urine  depositing  it  is  usuall}^  high-colored  and  acid ;  very 
rarely  neutral  or  faintly  alkaline ;  and  never,  so  far  as  I  have 
seen,  freely  alkaline.  Oxalate  of  lime  is  often  conjoined  with 
uric  acid  and  the  amorphous  urates ;  much  more  rarely  with  the 
stellar  phosphate  of  lime. 

Production  and  Occurrence. — The  frequent  occurrence  of 
oxalic  acid  in  the  urine  cannot  be  a  matter  of  surprise  when  it 
is  remembered  that  it  differs  from  carbonic  acid — one  of -the 

1  Thudichum  states  that  octahedra  of  oxalate  of  lime  do  polarize  light,  and 
that  there  is  no  reason  to  believe  that  the  dumb-bells  difter  from  them  in  compo- 
sition. 

2  Proceedings  of  Eoy.  Soc,  1867. 

^  The  precipitation  of  carbonate  of  lime  in  spheres  and  close  dumb-bells  in  the 
viscid  urine  of  the  horse  is  an  example  of  the  same  kind.  Mr.  Kainey  has  shown  a 
much  wider  application  of  the  same  principle  in  the  calcifications  which  take  place 
naturally  in  the  hard  tissues  of  the  body.     See  Med.-Chir.  Eev.,  vol.  xx.  p.  4-51. 


102  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

chief  final  products  of  the  disintegration  of  the  tissues — only  in 
possessing  half  an  atom  less  of  oxygen.  It  constitutes  probably 
one  of  the  penultimate  stages  in  the  series  of  decompositions 
through  which  the  effete  tissues  pass  preparatory  to  their  final 
exit  from  the  body.  A  large  number  of  substances  which  occur 
in  the  body  (uric  acid,  creatin,  fats,  starch,  sugar,  etc.)  can  be 
made  to  yield  oxalic  acid  in  the  laboratory;  and  it  is  highly 
probable  that  a  similar  change  occurs  in  the  living  economy. 
With  regard  to  uric  acid,  this  has  been  positively  ascertained  by 
Wohler;  and  Dr.  Garrod  has  succeeded  in  showing  that  oxalic 
acid  is  present,  sometimes  at  least,  in  the  blood. 

It  is  therefore  easy  to  understand  how  oxalic  acid  should  exist 
in  urine ;  also  that  it  may  be  partly  derived  from  the  blood  and 
appear  in  the  urine  at  the  moment  of  secretion,  and  partly  be 
produced  after  the  urine  is  secreted  by  conversion  from  uric 
acid.  Dr.  Owen  Rees  has  nevertheless  expressed  his  strong 
disbelief  in  the  existence  of  oxalate  of  lime  in  the  blood,  appar- 
ently on  the  ground  of  the  chemical  difiiculty  in  conceiving  that 
oxalate  of  lime,  from  its  insolubility,  could  exist  dissolved  in  the 
blood ;  he  contends  that  all  the  oxalate  of  lime  found  in  urine 
is  produced  from  uric  acid  after  separation  from  the  blood. ^ 
These  theoretical  objections,  however,  do  not  avail  against  the 
positive  fact,  that  oxalic  acid  and  its  compounds,  even  the  in- 
soluble oxalate  of  lime,  pass  through  the  blood  into  the  urine 
when  introduced  into  the  stomach.  "Wohler  found  that  oxalic 
acid  given  to  dogs  caused  oxalate  of  lime  to  appear  in  the  urine. 
Piotrowsk}^  confirmed  these  results  by  experiments  on  himself. 
He  took,  in  divided  doses,  from  80  to  100  grains  of  oxalic  acid 
in  the  course  of  about  six  hours,  and  found  that  from  8  to  14 
per  cent,  appeared  in  the  urine  as  oxalate  of  lime,  mixed  with  a 
little  alkaline  oxalate.  Similar  results  were  obtained  with  the 
oxalate  of  soda.  When  the  insoluble  oxalate  of  lime  was  taken 
in  the  same  doses,  very  much  less  of  it  appeared  in  the  urine ; 
still  about  1|  per  cent,  could  be  recovered.^ 

Clinical  Significance. — Distinction  must  be  made  between 
slight  occasional  deposits,  and  large  quantities  occurring  per- 
sistently. In  the  former  case,  it  cannot  be  said  positively  that 
there  is  any  departure  from  the  normal  state,  seeing  that  oxalic 
acid  is  in  all  probability  a  natural  constituent  of  urine;  at  least,  it 
is  constantly  found  in  the  urine  of  perfectly  healthy  individuals. 

But  when  the  deposit  is  constant  and  large,  an  abnormal  state 
must  be  recognized  to  exist;  and  we  are  called  upon  to  con- 

1  "  On  Calculous  Disease."     Croonian  Lectures  for  1856,  pp.  2  et  seq. 

2  Archiv  f.  Physiol.  Heilk.,  1857,  p.  122.  Dr.  Leared  and  Dr.  Dyce  Duck- 
worth have  also  found  that  taking  ^iij  of  lime-water  or  a  grain  of  oxalic  acid  caused 
oxalate  of  lime  crystals  to  appear  in  the  urine  of  healthy  persons.  St.  Barthol. 
Hosp.  Rep.,  1866,  p.  160;  and  Med.  Times  and  Gaz.,  1867,  I.  219. 


OXAJ.A'l'K    OF    LIMK.  103 

sider  what  puth()loii:;iciil  sii^niiicai)cc  it  rruiy  liuve,  and  vvhctlicr  it 
siipi)liuH  any  iiidicalionw  for  trcatrnojit. 

The  most  obvious  inference  18,  that  there  exists  in  such  a  case 
a  liability  to  the  formation  of  an  oxalate  of  lime  calculus.  'I'his 
point,  and  the  preventive  treatment  to  be  followed,  will  be  con- 
sidered in  the  section  on  calculous  disease. 

But  a  much  wider  significance  has  been  given  by  some  authors 
to  oxalate  of  lime  deposits;  and  a  certain  group  of  symptoms 
which  are  alleged  to  accompany  these  deposits,  has  been  erected 
into  a  distinct  pathological  state  under  the  name  of  the  oxalic 
acid  diathesis.  Dr.  Prout  was  the  lirst  to  promulgate  this  view; 
and  he  has  been  followed  by  Dr.  Bird  and  Dr.  Begbie.  Dr.  Bird 
gives  the  following  account  of  the  symptoms  which  accompany 
oxaluria:  "They"  (the  patients)  "are  generally  much  emaci- 
ated, excepting  in  slight  cases,  .extremely  nervous,  painfully 
susceptible  to  external  impressions,  often  hypochondriacal  to  an 
extreme  degree,  and  in  very  man}-  cases  labor  under  the  im- 
pression that  they  are  about  to  fall  victims  to  consumption. 
They  complain  bitterly  of  incapability  of  exerting  themselves, 
the  slightest  exertion  bringing  on  fatigue.  Some  feverish  excite- 
ment, with  the  palms  of  the  hands  and  soles  of  the  feet  dry  and 
parched,  especially  in  the  evening,  is  often  present  in  severe 
cases.  In  temper  they  are  irritable  and  excitable;  in  men  the 
sexual  power  is  generally  deficient  and  often  absent.  A  severe 
and  constant  pain,  or  sense  of  weight  across  the  loins,  is  gen- 
erally a  prominent  symptom,  with,  often,  some  amount  of  irri- 
tabilit}'  of  the  bladder.  The  mental  faculties  are  generally  but 
slightly  affected,  loss  of  memory  being  sometimes  more  or  less 
present."     ("Urinary  Deposits,"  5th  ed.,  p.  251.) 

This  train  of  sj^mptoms  is  familiar  enough  to  every  prac- 
titioner :  and  the  occurrence  of  oxaluria  in  such  cases  is  un- 
doubtedly common  enough  ;  but  these  symptoms  may  be  present 
in  typical  completeness  without  oxaluria,  and  conversely  oxaluria 
may  exist  in  its  highest  intensity,  and  even  go  on  to  the  forma- 
tion of  a  mulberry  calculus,  without  evoking  any  of  the  above- 
mentioned  symptoms.  Every  one  who  has  had  experience  in 
calculous  disorders  cannot  have  failed  to  observe  that  the  sub- 
jects of  mulberry  calculus,  especially  children,  are  not  unfre- 
quently  in  the  enjoyment  of  blooming  health  so  long  as  no  local 
irritation  has  been  set  up  by  the  concretion.  It  will  also  not 
fail  to  be  remarked  that  the  symptoms  attributed  to  oxaluria 
are  almost  identical  with  those  attributed  to  spermatorrhoea. 
Disturbed  equilibrium  and  loss  of  tone  of  the  nervous  system, 
with  symptoms  (more  or  less  intense)  of  impaired  digestion,  are 
unfortunately  a  too  common  resultant  of  the  intense  activity  of 
mind  and  body,  and  the  trying  wear  and  tear  of  modern  life : 
and  both  physician  and  patient  are  naturally  anxious  to  find 


104  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

some  material  alteration  to  account  for  a  condition  which  is 
sufficiently  serious,  and  which  is  remarkable  for  its  want  of  defi- 
nition. The  patient  often  fixes  on  some  derangement  of  the 
sexual  function,  generally,  in  these  times,  on  spermatorrhoea, 
under  the  inspiration  of  unscrupulous  publications  too  widely 
circulated  among  the  curious  public ;  or  on  heart  disease,  con- 
sumption, or  gravel.  The  physician  is  able  by  means  of  phy- 
sical examination  to  set  aside  these  more  open  delusions,  but 
falls  himself  into  the  trap  of  his  own  ingenuity,  and  is  only 
more  elaborately  wrong  than  his  patient.  He  finds  crystals 
of  oxalate  of  lime  in  the  urine,  and  persuades  himself  that  he 
has  discovered  the  first  link  in  the  chain  of  consequences.  It 
may  be  much  questioned  (and  I  certainly  see  no  necessit}^  for 
such  a  supposition)  whether  there  be  any  morbid  condition  ante- 
cedent to  the  plain  symptoms  of  the  case,  namely,  an  overtasked 
and  disturbed  nervous  system,  and  a  mismanaged  and  deranged 
digestion. 

The  facts  and  considerations  which  lead  to  the  above  reflec- 
tions are : 

1.  Intense  oxaluria  may  exist  persistently  without  evoking 
the  group  of  symptoms  attributed  to  the  oxalic  diathesis. 

2.  This  group  of  sj^mptoms  ma}^  exist  in  typical  development 
without  the  occurrence  of  deposits  of  oxalate  of  lime  in  the 
urine. 

3.  The  most  varied  morbid  states  are  found  to  coexist  with 
oxaluria.  I  have  been  in  the  habit  for  many  years  of  noting 
the  symptoms  and  pathological  states  of  those  patients  in  the 
Manchester  Infirmary  who  had  pronounced  oxalate  of  lime  de- 
posits, rive  out  of  every  six  exhibited  none  of  the  symptoms 
attributed  to  oxaluria.  Almost  every  variety  of  disease  was 
occasionally  found  associated  therewith.  The  following  espe- 
cially were  observed :  chronic  phthisis,  cardiac  afi'ections,  em- 
physema with  chronic  bronchitis,  chronic  rheumatism,  ansemia, 
hemiplegia,  malignant  disease  of  the  liver  and  stomach,  chronic 
vomiting,  and  cirrhosis. 

I  am  strongly  convinced,  that  oxaluria  arises  from  a  variety 
of  conditions — many  of  them  not  accompanied  by  appreciable 
departures  from  health — in  which  the  assimilation  of  food  or 
the  disintegration  of  the  tissues  goes  on  imperfectly;  .and  that 
it  is  impossible  to  assign  any  constant  train  of  symptoms  as  the 
cause  or  the  consequence  of  oxaluria.  At  the  most,  oxaluria 
is  only  one  in  a  long  list  of  symptoms,  and  one  of  the  least 
significant. 

Beneke,  who  has  subjected  this  question  to  an  elaborate  exami- 
nation, both  in  the  way  of  experiment  and  observation,  has 
formulated  the  following  propositions,  which  appear  to  me  to  be 
well  founded : 


OXALATE    OK    LIMK.  105 

1.  Oxaluria,  a  condition  which  accorn[)HnicH  the  litz;}jlor  of 
severer  forms  of  illness,  has  its  proximate  cause  in  an  impeded 
metamorphosis — that  is,  in  an  insufficient  activity  of  that  stage 
of  oxidation  which  changes  oxalic  acid  into  carhonic  acid. 

2.  Oxalic  acid  has,  if  not  its  sole,  its  chief  source  in  the  azo- 
tized  constituents  of  the  blood  and  food;  everything,  tljerefore, 
which  retards  the  metamorphosis  of  these  constituents  occasions 
oxaluria, 

3.  Such  a  retardation  of  the  metamorphosis  of  the  azotized 
constituents  of  the  blood  may  be  determined  by  the  following 
causes : 

a.  Abuse  of  azotized  articles  of  food  (direct  retardation). 

b.  Abuse  of  saccharine  and  starchy  articles  of  food  (indirect 
retardation). 

c.  Insufficiency  of  the  red  blood-corpuscles  and  (eventually) 
diminished  oxidation. 

d.  Insufficient  enjoyment  of  pure,  fresh,  ventilated  air. 

e.  Organic  lesions  which  in  any  way  impede  respiration  and 
the  circulation  of  the  blood. 

/.  Conditions  of  the  nervous  system  which  bear  a  character 
of  depression,  wdiether  these  arise  primarily  from  mental  de- 
rangement or  from  pathological  states  of  the  blood. 

4.  Excess  of  alkaline  bases  in  the  blood,  which,  as  numerous 
observations  tend  to  show,  plays  an  important  part  among  the 
etiological  conditions  of  oxaluria;  and  it  is  not  improbable  that 
an  increased  production  of  lactic  and  butyric  acids  in  the  diges- 
tive canal,  consequent  thereupon,  impedes  the  development  of 
the  red  blood-corpuscles,  and  thereby  generates  that  chlorotic 
state  which  so  often  occasions  and  accompanies  oxaluria. 

5.  Catarrhal  conditions  of  the  intestinal  mucous  membrane, 
in  case  they  are  accompanied  by  oxaluria,  have  at  most  only 
a  common  source.  They  may  determine  oxaluria  by  causing 
deranged  digestion,  but  cannot  be  considered  as  its  proximate 
cause.'^ 

Treatment, — After  the  foregoing  reasoning  and  conclusions, 
it  is  scarcely  necessary  to  say  that  oxaluria  does  not,  in  the 
opinion  of  the  present  writer,  furnish  special  indications  for 
treatment ;  nevertheless  it  will  be  found  that,  apart  from  the 
existence  of  organic  disease,  the  conditions  most  frequently 
found  associated  with  oxaluria,  varied  as  they  are,  call  for  a  toler- 
ably uniform  therapeutical  action.  They  demand  a  quickening 
of  the  oxidation  processes,  and  a  careful  regulation  of  the  diet. 
The  skin  should  be  encouraged  to  activity  by  systematic  use  of 
cold  sponging,  friction  of  the  skin  with  flesh-brushes,  wearing 

^  Zur  Entwicklungsgeschichte  d.  Oxiilarie,  bv  E.  W  Beneke.  Gottingen, 
1852. 


106  CHEMICAL    COXSTITJENTS    OF    THE     URINE. 

of  flannel  vests  and  drawers,  regulated  exercise  in  the  open  air 
— if  available,  horse  exercise.  Many  of  the  cases  yield  only  to 
repeated  change  of  air ;  the  bracing  atmosphere  of  upland  and 
sea-side  localities  generally  suits  the  best.  It  will  often  be  found 
advantageous  to  withdraw  for  a  time  the  use  of  tea  and  coffee, 
and  to  substitute  milk;  or  if  this  prove  heavy,  milk  mixed  with 
one-fourth  of  lime-water.  The  diet  should  be  judiciously  com- 
pounded of  due  proportions  of  animal  and  vegetable  substances 
— diminishing  the  one  or  the  other  group  of  aliments  according 
to  the  ascertained  idiosyncrasy  of  the  patient.  He  must  be 
cautioned  against  heavy  meals,  and  trained  to  partake  more 
moderately  of  four  meals  a  day.  Digestion  may  be  promoted 
by  the  administration  of  the  mineral  acids  in  light  bitter  infu- 
sions, or  by  small  doses  of  the  bicarbonate  of  potash  in  the  same 
combination.  It  is  not  easy  to  determine  beforehand  which  of 
these  opposite  medicaments  will  prove  most  grateful  to  the 
stomach.  The  rule  of  choice  is,  to  administer  the  acid  when 
the  dyspeptic  symptoms  point  to  an  atonic  state  of  the  organ 
and  of  the  body  generally,  and  the  alkali  when  the  signs  point 
to  gastric  and  general  irritation. 

YI.— CYSTINE  (CgH^NSO^). 
[Synonym — -cystic  oxide.) 

Cystine  or  cystic  oxide  is  a  crystalline  body  of  great  rarity,, 
v^hich  is  found  only  under  certain  abnormal  conditions  in  the 
bodies  of  animals.  Hitherto  it  has  been  detected  with  certainty 
only  in  man  and  the  dog.  Oloetta  asserts  that  he  found  it  once 
in  the  kidneys  of  an  ox. 

Cystine  was  discovered  by  Wollaston  in  1805,  in  a  urinary 
calculus  which  was  mainly  composed  of  it.  Since  that  time  a 
considerable  number  of  cystine  calculi  have  been  found  in  dif- 
ferent parts  of  Europe  and  America;  but,  as  compared  with 
other  urinary  concretions,  this  is  one  of  the  most  rare. 

As  a  urinary  deposit,  cystine  has  been  even  less  frequently 
met  with  than  as  a  calculus ;  and  as  nothing  is  known  touching 
the  organic  processes  and  constitutional  states  in  which  cystine 
is  produced,  the  clinical  interest  attaching  to  it  is  for  the  most 
part  conflned  to  its  manifestations  as  gravel  and  calculus.  A 
number  of  cases  have,  however,  been  observed  where  cystine 
existed  simply  as  a  urinary  deposit,  or  dissolved  in  the  urine. ^ 

1  Niemann  (Deutscli.  Arch.  f.  klin.  Medicin,  Bd.  xviii.  p.  232)  has  collected  52 
cases  of  cystinuria.  The  following  additional  cases  may  be  referred  to  :  Loebisch, 
Liebis's  Annalen,  182;  Southam,  Brit.  Med.  Journ:,  II.,  1876,  and  II.,  1878; 
Guyot,  Progres  Medical,  1878,  No,  10;  Ebstein,  Deutsehes  Arch.  f.  klin.  Med., 
Bd.  xxiii.  ;  Ultzmann,  Med.  Pr.,  No.  29,  1878;  Wood,  Bost.  Med.  and  Surg. 
Journal,  1878. 


0  Y  S  '1'  1 N  K . 


107 


The  followiTiii;'  case  of  cy>stine  calculuH  witli  coiicurront  cjKti- 
niiria  occurred  in  the  Matiche.ster  Iniirmary  : 

J.  M.,  set.  57,  admitted  June  15,  1874.  There  was  no  history  of  stone 
or  gravel  in  any  member  of  his. family.  He  was  quite  healthy  until 
January,  1873,  when  he  sulfered  from  repeated  attacks  of  renal  colic. 
In  April,  1873,  symptoms  of  vesical  calculus  appeared,  and  these  have 
wmtinued  ever  since.  On  sounding,  a  stone  was  found  in  the  bladder. 
The  urine  contained  a  good  deal  of  pus,  and  under  the  microscope 
numerous  well-formed  hexagonal  crystals  of  cystine  were  detected 
(Fig.  14). 


Fig.  14. 


Crystals  of  cystine  spontaneoiTsly  voided  with  tlie  urine  of  J.  M. 

This  man  was  subjected  to  one  sittins:  with  the  lithotrite  by  Mr. 
Southam.  Much  irritation  of  the  bladder  followed,  with  severe  bron- 
chitis, of  which  the  patient  died  a  fortnight  after  the  operation.  After 
death  extensive  pyelitis  with  sacculation  of  the  kidneys  was  found ;  and 
broken  portions  of  a  cystine  calculus  were  discovered  in  the  bladder. 

Generally,  urine  depositing  cystine  is  turbid  when  voided; 
and  on  standing,  a  copious  light  sediment  subsides,  much  re- 
sembling (to  the  naked  eye)  fawn-colored  lithates.  The  urine 
from  which  cystine  is  deposited  has  sometimes  a  peculiar  sweet- 
briar  odor,  a  honey-yellow  color,  and  an  oily  appearance.  It  ts 
usually  faintly  acid  and  very  liable  to  spontaneous  decomposi- 
tion, in  the  course  of  which  it  evolves  sulphuretted  hydrogen, 
and  blackens  white  glass  vessels.  Dr.  Golding  Bird  observed 
that  urine  containing  cystine  changed  from  yellow  to  green  when 
it  became  decomposed. 

A  few  drops  of  acetic  acid  always  precipitate  an  additional 
quantity  of  cystine  from  the  supernatant  urine;  and  if  a  urine 


108 


CHEMICAL    CONSTITUENTS    OF    THE    URINE, 


containing  cystine  holds  it  all  in  solution,  as  may  happen  when 
the  quantit}''  is  very  small,  acetic  acid  throws  it  down. 

A  deposit  of  cystine  is  not  dissolved  by  heat,  nor  by  the  vege- 
table acids.  It  is  instantly  dissolved  by  caustic  ammonia,  and 
if  the  solution  be  exposed  in  a  watch-glass  to  evaporation  in  the 
air,  beautiful  six-sided  crystals  are  obtained  as  the  volatile  alkali 
exhales  (Fig.  15).     This  is  the  characteristic  reaction  of  cystine, 


Fig.  15. 


Cystine.     Hexagonal  tablets  and  prisms  from  an  evaporated  ammoniacal  solution. 

and  leads  to  its  easy  identification.  Cystine  is  also  soluble  in 
the  carbonates  of  the  fixed  alkalies ;  but  not  in  carbonate  of 
ammonia,  which,  indeed,  is  its  best  precipitant  from  acid  solu- 
tions. It  is  soluble  also  in  the  mineral  acids,  but  insoluble  in 
acetic  and  tartaric  acids.  It  is  insoluble  in  water  and  alcohol. 
Heated  on  platina  foil,  it  evolves  thick  white  fumes,  having  a 
peculiar  offensive  odor  resembling  garlic. 

Cystine  is  a  body  of  very  weak  aflinities,  without  taste  or 
smell ;  it  acts  as  a  feeble  base,  and  forms  crj^stalline  compounds 
with  nitric  and  hydrochloric  acids.  According  to  Pelouze,  it 
may  also  play  the  part  of  an  acid;  he  obtained  two  compounds 
with  silver,  which  he  denominated  cystates.^ 

A  spontaneous  deposit  of  cystine  in   urine  is   composed  of 

1  "Note  sur  la  cystine,"  'by  Peloiize,  appended  to  Civiale's  M^moire  sur  les 
calculs  de  cystine,  at  p.  441  of  Civiale's  treatise  Du  traitement  medical  de  la  pierre. 
Some  further  consideration  respecting  the  constitution  and  physiological  relations 
of  cystine  may  be  found  in  a  paper,  by  J.  Dewar  and  A.  Gamgee,  in  the  Journ. 
for  Anat.  and  Physiol.,  1870. 


CYSTINE.  109 

hexagonal  tablets.  Wlieu  the  aininoniacal  solution  of  cystine 
is  allowed  to  evaporate  in  the  air,  magnificent  crystals  are 
obtained,  which  furnish  brilliant  o]>jects  for  the  microscope. 
Cystine  is  dimorphous,  and  crystallizes  in  two  forms,  namely, 
as  six-sided  tablets  and  square  prisms  {see  Fig.  15). 

The  ammoniacal  solution  generally  deposits  hexagonal  plates 
only,  or  these  mixed  with  a  few  prisms;  sometimes,  however, 
the  prisms  are  more  abundant  than  the  plates.  The  prisms 
either  lie  singly  or  form  stars:  they  refract  light  strongly,  and 
the  facets  which  lie  slantingly  out  of  the  direct  line  of  vision 
appear  perfectly  black,  contrasting  with  the  brilliant  lustrous 
white  of  the  planes  through  which  the  light  passes  vertically. 
This  gives  a  peculiar  striped  appearance  to  the  prisms,  and  causes 
them  to  appear  deceptively  six-sided.  The  hexagonal  tablets 
have  an  iridescent  mother-of-pearl,  lustre;  their  surfaces  are 
often  beautifully  chased  by  lines  of  secondary  crystallization ; 
they  also  form  thick  rosettes  of  great  brilliancy. 

The  production  of  cystine  in  the  animal  body  has  as  yet  re- 
ceived no  elucidation.  It  may,  hoAvever,  be  assumed  that  it 
preexists  in  the  blood,  and  is  merely  separated  by  the  kidneys. 
The  most  remarkable  fact  respecting  the  constitution  of  cystine 
is  the  large  amount  of  sulphur  (nearly  26  per  cent.)  v^hich  it 
contains.  The  close  analogy  of  composition  between  it  and 
taurine,  renders  it  not  improbable  that  the  liver  is  the  origi- 
nal source  of  cystine;^  the  discovery  of  cystine  in  the  livers  of 
typhus  patients  by  Scherer^  lends  support  to  this  view;  and 
Marowsky^  also  found  cystinuria  accompanying  a  diminished 
secretion  of  bile.  Later  researches,  however,*  have  thrown  doubt 
on  this  theory. 

Ebstein  has  reported  a  case  in  which  cystinuria,  accompanied 
by  albuminuria,  suddenly'  occurred  in  the  course  of  joint  rheuma- 
tism, the  joint  pains  at  the  same  time  diminishing.  After  about 
a  fortnight's  duration,  the  albumen  and  the  cystine  suddenly 
disappeared  from  the  urine. 

The  other  constituents  of  the  urine  have  not  been  found 
altered  in  any   constant  manner  in   cystinuria;  and  the  later 

1  The  close  connection  between  cystine  and  taurine  may  be  gathered  at  a  glance 
by  a  comparison  of  their  composition  per  cent. : 

Cystine.  Taurine. 

Carbon 30.00  19.20 

Hydrogen 5.00  5.00 

NitrogW 11.66  11.20 

O^xygen 26.66  38.40 

Sulphur 26.66  25.60 

2  Arcbiv  f.  Path.  Anat.,  Bd.  x.  p.  228. 

3  Deutsch.  Arch.  f.  Idin.  Medicin,  Bd.  iv.  p.  449. 
*  See  Niemann,  loc.  cit.  p.  232. 


110  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

analyses  of  Beale^  and  ToeP  tend  to  support  the  original  opinion 
of  Civiale,  that  in  cystinuria,  as  in  most  other  calculous  states, 
the  composition  of  the  urine,  apart  from  the  dominant  calculus- 
forming  constituent,  is  normal.  It  would  be  of  interest  to  de- 
termine the  amount  of  unoxidized  sulphur  voided  with  the  urine 
in  these  cases.  When  it  is  remembered  that  from  3  to  5  grains 
of  unoxidized  sulphur  are  daily  discharged  with  the  urine  by 
healthy  men,^  it  would  seem  a  priori  not  improbable  that  cystine 
is  onW  the  sulphur  extractive  in  a  new  form.  If  it  be  so,  one 
would  expect  the  unoxidized  sulphur  to  be  diminished  in  cys- 
tinuria. The  excretion  of  sulphuric  acid  was  not  found  dimin- 
ished in  a  case  examined  by  Beale.  Loebisch  and  Memann, 
however,  have  observed  in  their  cases,  that  the  total  amount  of 
sulphuric  acid  excreted,  calculated  absolutely  and  also  in  rela- 
tion to  the  nitrogen  present,  was  somewhat  less  than  normal. 

Niemann  also  found  a  diminution  of  the  uric  acid  excreted, 
but  Ebstein  came  to  the  conclusion  that  a  diminution  of  urea, 
uric  acid,  or  sulphuric  acid  could  not  be  proved  in  cystinuria. 

Deposits  of  cystine  are  very  bulky;  but  the  quantity,  when 
weighed,  is  found  unexpectedly  small.  Percentage  determina- 
tions have  been  made  by  Prout  and  Beale.  The  former  found 
0.024,  and  the  latter  0.09.  Loebisch  and  ISTiemann  have  each 
determined  the  daily  excretion,  and  have  obtained  as  the  daily 
average  0.393  grain  and  0.509  grain  respectively. 

Cystine  may  persist  in  the  urine  for  many  years ;  it  may  dis- 
appear for  a  while,  and  reappear  again  after  a  longer  or  shorter 
interval ;  or  it  may  disappear  permanently.  It  is  sometimes 
succeeded  by  deposits  of  uric  acid.  The  connection  of  cystine 
in  the  urine  with  deposits  of  the  earthy  phosphates,  on  which 
Prout  and  Civiale  insist,  is  probably  nothing  more  than  a  coin- 
cidence depending  on  the  strong  tendency  of  urine  containing 
cystine  to  decompose  and  become  ammoniacal,  whereby  the 
phosphates  are  necessarily  precipitated. 

One  of  the  most  curious  circumstances  in  the  history  of  cys- 
tine is  the  unquestionable  tendency  which  it  shows  to  run  in 
families.  The  facts  bearing  on  this  point  will  be  referred  to  in 
treating  of  cystine  calculus. 

Cystine  has  been  found  more  commonly  in  males  than  in 
females,  and  mostly  in  children  and  young  adults ;  though  no 
age  is  exempt.  Dr.  Shearman,  of  Rotherham,  believes  that 
scrofulous  children  and  chlorotic  females  are  especially  liable  to 
cystinuria.     In  a  j^oung  woman  from  whom  Mr.   Jordan  ex- 

^  Urine  and  Urinary  Calculi,  p.  311. 

2  Ann.  der  Cbem.  u.  Pliarm.,  Ed.  xcvi.  p.  24. 

^  Konalds  :  Phil.  Trans.,  1847,  p.  461.  The  observations  of  Konalds  have^,been 
since  confirmed  by  Griffith  and  Parkes.  The  same  has  been  found  in  the  urine  of 
dogs  by  Bischoff  and  Yoit. 


XANTHINE.  Ill 

tractcd  a  cystine  calculus  Borrie  years  ago,  in  the;  jMancliCKlei- 
Infirmary,  I  found  considerable  tuberculous  consolidation  of 
both  apicos.  The  more  recent  researches  of  Fabre'  do  not  su])- 
port  the  opinions  of  Dr.  Shearman.  Fabre  examined  the  urine 
of  a  large  number  of  tu])erculous  persons  and  of  thirty-six 
strumous  children,  but  failed  to  detect  a  trace  of  cystine.  In 
fifteen  chlorotic  females  he  likewise  obtained  negative  results. 

It  is  undoubted  that  persons  niay  void  cystine  for  years,  with- 
out any  other  deviation  from  health  than  what  is  caused  by  the 
physical  irritation  of  the  concretions,  when  these  form.  The 
brothers  Planta,  operated  on  by  Civiale  for  immense  cystine 
calculi,  were  known  to  have  been  excreting  cystine  in  (quantity 
for  six  years  continuously,  without  any  impairment  of  health. 
The  sisters  observed  by  Toel  looked  well,  and  were  perfectly 
healthy,  except  that  they  were  liable  to  nephritic  pains  from 
time  to  time,  when  they  passed  small  calculi  and  gravel. 

The  clinical  significance  of  cystine  is  therefore  chiefl}^,  if  not 
wholly,  the  danger  of  the  formation  of  stone  and  gravel. 

The  treatment  of  cystinuria,  apart  from  that  which  is  designed 
to  prevent  the  formation  of  concretions,  is  necessarilj^,  so  long 
as  the  rationale  of  its  production  is  so  obscure,  unsatisfactory. 
Dr.  Prout  believed  he  saw  benefit  from  the  long-continued  use 
of  nitro-muriatic  acid.  Dr.  Bird,  on  the  other  hand,  found 
the  same  remedy  useless.  If  chlorosis  or  struma  coexist  with 
cystinuria,  these  will  of  course  demand  their  appropriate  treat- 
ment; but  as  yet  nothing  is  known  which  can  i:)retend  to  have 
any  direct  influence  in  checking  the  formation  of  cystine. 

VII.— XANTHINE  (CgH^N^OJ. 
•  [Synonyms — xanthic  oxide ;  U7'ic  oxide.) 

This  rare  substance  was  originally  discovered  by  Dr.  Marcet, 
about  the  year  1817,  in  a  urinary  calculus  given  to  him  by  Dr. 
Babington.  This  concretion  weighed  only  8  grains,  and  had 
apparently  been  passed  spontaneously.  In  1816  the  elder  Lang- 
enbeck  removed  from  a  peasant  boy,  eight  years  of  age,  a  stone 
as  large  as  a  small  egg,  which  was  afterwards  identified  by 
Stromeyer  with  the  xanthic  oxide  or  xanthine  of  Marcet.  In 
1837  a  portion  of  this  stone  was  analyzed  by  Liebig  and  Wohler  ;'- 
in  1846  it  was  reexamined  by  Bodo  linger^  with  identical  re- 
sults.    The  name  Xanthine  was  originally  used  by  Unger  to 

'  A.  Fabre  :  De  la  cystine,  etc.  Paris  Tliesis,  1859.  Fabre  calls  attention  to 
the  hexagonal  appearance  of  uric  acid  crystals  when  precipitated  by  acetic  acid  ; 
and  he  attributes  the  conclusions  of  Shearman  to  confounding  these  with  cystine 
crystals. 

2  Poggend.  Ann.  der  Physix,  1837,  Bd.  xli.  p.  393. 

3  Liebig's  Ann.  der  Chem.  und  Pharm.,  Bd.  Iviii.  p.  17. 


112  CHEMICAL    CONSTITUENTS    OF    THE    UKINE. 

designate  a  substance  found  by  him  in  guano,  which  he  at  first 
considered  identical  with  Marcet's  xanthic  oxide,  but  which  he 
subsequently  established  as  a  new  substance  under  the  name  of 
guanine;  tlie  name  xanthine  then  passed  permanently  to  Mar- 
cet's xanthic  oxide. 

In  1829,  Laugier^  described  some  minute  calculi  obtained 
from  a  patient  who  had  passed  several.  Three  of  these  were 
handed  over  to  Laugier;  the  largest  of  them  weighed  less  than 
one-sixth  of  a  grain.  Their  deep  yellow  color,  their  spherical 
form,  their  smooth  surface,  seemed  to  indicate  that  they  con- 
sisted of  uric  acid.  They  proved,  however,  to  be  xanthine, 
and  yielded  the  characteristic  reaction  with  nitric  acid  and 
potash. 

Professor  Dulk,  of  Konigsberg,  removed  a  xanthine  calculus 
weighing  7  grains  from  the  urethra  of  a  bo}^  (Bird). 

In  1866,  Mr.  T.  Taylor  discovered  in  the  Museum  of  the 
London  College  of  Surgeons  a  calculus  composed  of  nearly  pure 
xanthine.  When  entire  it  weighed  90  grains.  It  was  extracted 
from  a  Mussulman  child,  four  years  old,  by  Mr.  Coles,  a  surgeon 
in  the  employ  of  the  East  India  Company.^ 

Xanthine  is  a  substance  closely  connected  with  uric  acid, 
differing  from  it  in  composition  only  in  possessing  one  atom 
less  of  oxygen.  Xanthine  has  been  discovered  by  Scherer  in 
the  blood ;  also  in  the  muscles,  liver,  spleen,  and  brain.  Scherer* 
further  states  that  a  very  minute  quantity  of  xanthine  is  a  natu- 
ral constituent  of  healthy  urine.  Heller  has  been  unable  to 
convince  himself  of  the  correctness  of  this  statement.'' 

Xanthine  has  been  met  with  five  times  (as  above  recorded)^ 
as  a  urinary  calculus  :  as  a  urinary  deposit  it  is  alleged  to  have 
been  encountered  by  Bird,  Douglas  Maclagan,  and  Bence  Jones. 
Maclagan  found  it  mixed  with  earthy  phosphates  in  the  urin^ 
of  a  hysterical  girl.^  Dr.  Bence  Jones's  case  was  a  school-boy 
between  nine  and  ten  years  of  age.  Three  years  before  he  had 
suffered  an  attack  resembling  nephritic  colic,  but  without  sub- 
sequent passage  of  a  stone.  When  first  seen,  the  urine  made  at 
night  contained  a  small  quantity  of  albumen,  but  that  of  the 
morning  contained  none.  A  month  later  the  urine  was  found 
"  quite  thick  and  deep  colored.  A  drop  was  placed  under  the 
microscope,  and  a  crystalline  deposit  was  found  resembling  one 
form  of  uric  acid.     From  this  form  T  considered  the  deposit 

^  Journ.  de  Chim.  Med.,  vol.  v.  1st  series. 

2  Path.  Soc.  Trans.,  xix.  275. 

=*  Liebig's  Ann.  d.  Ch.  u.  Ph.,  Bd.  cvii.  Heft  3,  1858. 

*  Heller's  Harnconcretionen,  p.  131,  note. 

^  A  short  mention  of  two  other  cases  which  occurred  in  America  is  found  in  the 
Brit.  Med.  Journ  ,  Jany.  1883,  p.  148. 

*•  Edin.  Med.  Journ.,  1858,  p.  121.  Scherer  doubts  this  case;  and  thinks  the 
reaction  mentioned  by  Maclagan  insufficiently  characteristic. 


X  AINTIJINE.  113 

was  uric  acid — (the  crystals  were  pointed  ovhIh).  On  oxaniinin_<^ 
the  unfiltered  urine  for  albumen  by  heat,  I  was  sur[)rised  to  see 
the  crystalline  deposit  entirely  dissolve.  A  fresh  portion  of 
sediment  showed  the  same  crystalline  appearance  and  the  same 
solubility  by  heat.  ...  A  day  or  two  afterwards  another  speci- 
men was  brought  to  me,  containing  tiie  same  crystalline  deposit 
soluble  by  heat.  The  sediment  formed  about  an  eigbth  of  tlj(; 
bulk  of  the  fluid.  It  was  collected  on  a  filter,  washed  with 
alcohol,  and  it  gave  the  following  reactions :  It  dissolved  in 
water  and  hydrochloric  acid;  when  treated  with  nitric  acid  it 
dissolved  without  effervescence,  and  when  evaporated  to  dry- 
ness it  left  a  yellow  residue."'  Further  examination  of  the 
urine  on  subsequent  occasions  yielded  no  traces  of  xanthine. 

Jackson  thought  he  detected  xanthine  in  diabetic  urine;  but 
the  tests  he  relied  on  were  untrustworthy.  Lehmann  was 
unable  to  detect  xanthine  in  several  diabetic  urines  which  he 
examined. 

Purified  xanthine,  according  to  Stadeler  (who  operated  on 
xanthine  obtained  from  Langenbeck's  calculus),  shows  itself 
under  the  microscope  as  very  small  irregular  granules.  When 
dried  it  forms  brittle  crusts,  almost  chalk-white,  with  a  slight 
tinge  of  yellow,  which  become  deeper-colored  when  powdered. 
When  rubbed,  xanthine  acquires  a  waxy  lustre.  It  is  soluble 
in  alkalies,  also  moderately  freely  in  concentrated  and  warm 
hydrochloric  acid.  This  solution  becomes  turbid  on  cooling, 
and  deposits  quadratic  octahedra  of  a  combination  of  xanthine 
with  the  acid.  It  dissolves  without  effervescence  in  nitric  acid, 
and  the  solution  on  evaporation  leaves  a  bright  yellow  residue, 
which  becomes  violet-red  when  treated  with  solution  of  caustic 
potash,^  The  solubility  of  xanthine  in  water  is  subject  to  extra- 
ordinary variations,  which  are  not  yet  understood.  Stadeler 
found  pure  xanthine  from  Langenbeck's  calculus  to  dissolve  in 
13,333  parts  of  cold  and  in  1178  parts  of  hot  water.  Strecker 
found  artificial  xanthine,  prepared  by  him  from  guanine,  to 
vary  in  its  solubility  according  as  it  was  obtained  from  the 
evaporated  ammoniacal  solution  or  precipitated  from  its  alka- 
line solutions  by  acetic  acid.  In  the  former  case  the  solubility 
in  hot  water  was,  in  round  numbers,  1  in  1350;  but  in  the  latter, 
1  in  396.  Prolonged  boiling  was  found  by  Strecker  to  lessen 
the  solubility  of  xanthine  in  hot  water.* 

1  Journal  of  Chemical  Societj',  Feb.  1862,  p.  79.  It  may  he  remarked  that  in 
no  previous  account  of  xanthine  have  c7-i/stals  of  that  substance  been  found.  It 
is  to  be  wished  that  in  Dr.  B.  Jones's  case  the  identification  of  xanthine  had  been 
more  perfect. 

2  Strecker,  Liebig's  Ann.,  May,  1861,  Bd.  cxviii.  p.  158. 

•^  Ibid.,  p.  168.  See,  also,  a  recent  paper  "  Sur  la  Xanthine  et  sa  recherche 
dans  les  calculs  vesicaux."     Lebon.  Comptes  Kendu?,  Ixxiii.  47. 


114 


CHEMICAL    CONSTITUENTS    OF    THE    URINE. 


VIII.— LEUCINE  AND  TYROSINE. 

These  two  substances  were  found  by  Stadeler  and  Frerichs 
in  the  urine  in  tj'phoid  fever  and  acute  yellow  atrophy  of  the 
liver.  Tyrosine  has  even  been  found  to  form  a  natural  urinary 
deposit  in  the  latter  disease.  This  deposit  is  described  by 
Frerichs  as  a  greenish-yellow  crystalline  sediment,  which  in- 
creases considerably  with  slight  evaporation  of  the  urine. 
Under  the  microscope,  greenish-yellow  globular  masses,  com- 
posed of  acicular  crystals,  are  seen.  In  one  of  Frerichs's  cases 
of  acute  yellow  atrophy,  he  says  of  the  urine  :  "  After  standing 
in  the  cold  air,  a  greenish-yellow  light  sediment  was  deposited, 
consisting  entirely  of  acicular  crystals  of  tyrosine  aggregated 
together  in  globular  masses.  When  a  drop  of  urine  was  evapo- 
rated on  a  watch-glass,  it  left  behind  a  residuum,  which,  upon 
microscopical  examination,  was  found  to  be  almost  exclusively 
composed  of  the  most  characteristic  possible  crystals  of  leucine 
and  tyrosine,  partly  saturated  with  coloring  matter."^  Frerichs 
regards  the  occurrence  of  these  deposits  as  of  great  importance 
in  the  diagnosis  of  acute  yellow  atrophy  of  the  liver. 

In  May,  1865,  my  then  clinical  assistant,  Mr.  Clements, 
brought  me  a  specimen  of  urine  passed  by  a  young  woman 

Fig.  16. 


Tyrosine,  spontaneoiisly  deposited  from  the  urine  of  a  patient  witli  acute  yellow  atrophy  of  the  liver. 

who  was  suffering  (and  died  the  day  atter)  from  acute  yellow 
atrophy  of  the  liver,  in  the  home  district  of  the  Manchester 
Infirmary.  After  standing  forty-eight  hours,  it  had  deposited 
an  abundant  sediment  of  tyrosine,  crystallized  in  sheaf-like 
bundles  of  acicular  crystals  {see  Fig.  16). 

1  Frerichs  on  Dis.  of  Liver,  Syd.  Soc.  Trans.,  vol.  i.,  Frontispiece,  Fig.  5,  and 
p.  220. 


PHOSPHORIC    ACID    AND    THK    PHOSPHATES.  115 

Friinkel'  found  leucine  and  tyroHine  in  the  urine  in  caseH  of 
poisoning  by  phosphorus. 

Xanthine,  hijpoxanthine,  guanine,  ii/rosijie,  leucine,  creatine,  and 
creatinine,  may  be  all  regarded  as  intermediate  steps  in  the  re- 
gressive nietamor[>li()si8  of  azotized  tissues  of  wliioh  the  ultimate 
stages  are  urea,  uric  acid,  water,  and  carbonic  acid.  It  is 
therefore  not  surprising  that  they  should  )>e  found  in  small 
quantities  in  the  tissues  and  the  blood ;  and  that  a  retardation 
of  this  metamorphosis  in  some  particular  stage  should  occasion 
their  appearance  in  the  urine. 

Hitherto  their  clinical  significance  has  not  been  made  out 
with  sufticient  clearness  to  be  of  practical  service;  and  the  cir- 
cumstance that  (except  xanthine  and  tyrosine)  they  never  form 
spontaneous  urinary  deposits,  removes  them  (at  present)  from 
the  interest  and  view  of  the  practitioner.  But  it  is  not  improb- 
able that  the  study  of  these  bodies  in  the  urine  may  hereafter 
lead  to  important  clinical  indications;  until  then,  it  is  not 
desirable  to  load  a  practical  work  like  the  present  with  details 
respecting  them,^ 

IX.— rHOSPHOEIC  ACID  AND  THE  PHOSPHATES. 

Phosphorus  exists  in  the  animal  body  in  large  quantities, 
Either  oxidized  into  phosphoric  acid,  and  united  with  bases  so 
as  to  form  phosphates  which  pervade  the  fluids  and  solids — 
especially  the  bones  ;  or  unoxidized,  and  combined  wath  albu- 
minous compounds  in  some  manner  not  yet  understood. 

Phosphoric  acid  passes  out  of  the  body  partly  with  the  feces 
and  partly  with  the  urine.  The  diurnal  excretion  of  phosphoric 
acid  by  the  kidneys  varies  from  30  to  90  grains.  The  mean  of 
twenty-live  sets  of  observations  collected  by  Dr.  Parkes,  was 
48.80  grains  a  day.  Tw^o-thirds  or  three-fourths  of  this  are 
combined  with  potash  and  soda  to  form  soluble  phosphates, 
which  do  not  come  under  the  notice  of  the  practitioner  as  uri- 
nary deposits.  The  remainder  is  united  with  lime  and  magnesia 
to  form  salts,  which,  though  soluble  in  acid  urine,  are  speedih^ 
precipitated  when  the  secretion  becomes  alkaline,  and  constitute 
urinary  deposits. 

Phosphoric  acid  is  derived  in  part  directly  from  the  food;  in 
part  also  from  the  oxidation  within  the  body  of  the  phosphorus 
of  the  albuminoid  tissues.  The  hourly  excretion  of  phosphoric 
acid  rises  considerably  after  meals;  and  the  earthy  phosphates 
undergo  a  proportionately  larger   increase  than  the   alkaline 

'   Berl.  klinisch.  Wochensch.,  1878,  p   265. 

2  A  paper,  by  K.  B.  Hoffmann,  in  Virchow's  Arohiv,  Bd.  48,  p.  358,  may  be 
referred  to  as  containing  a  large  amount  of  information  respecting  the  excretion 
of  creatinine  in  health  and  disease. 


116  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

phosphates.  In  a  series  of  observations  extending  over  six 
days,  I  found  that  the  average  hourly  separation  of  the  earthy 
phosphates  during  the  two  hours  preceding  dinner,  amounted 
only  to  one-half  the  quantity  separated  during  the  third  and 
fourth  hours  after  dinner.  The  alkaline  phosphates  rose  from 
3.47  grains  per  hour  before  dinner,  to  4.90  grains  after  dinner. 

The  food  is,  however,  not  the  sole  source  of  the  phosphoric 
acid  of  the  urine;  and  the  separation  of  it  goes  on,  though  in 
greatly  diminished  quantity,  after  prolonged  fasting. 

A  very  large  number  of  observations  has  been  made  on  the 
excretion  of  phosphoric  acid  in  disease,  but  with  results  of 
slight  clinical  value.  Dr.  Bence  Jones  has  formulated  the  fol- 
lowing conclusions  (founded  on  determinations  per  1000  parts) : 
"  In  acute  inflammation  of  the  brain,  there  is_  an  excessive 
amount  of  phosphates  in  the  urine.  When  the  inflammation 
becomes  chronic,  no  excess  of  phosphates  can  be  shown  to  exist. 
...  In  some  functional  diseases  of  the  brain,  an  excessive 
amount  of  phosphates  is  observable ;  this  ceases  with  the  de- 
lirium. Delirium  tremens  shows  a  remarkable  deficiency  in 
the  amount  of  phosphates  excreted,  provided  no  food  is  taken. 
"When  food  is  taken  the  diminution  is  not  apparent."^  These 
observations  are  substantially  borne  out  by  the  observations  of 
Tomowitz  and  Beale. 

Professor  Yogel  ascertained  the  rate  of  excretion  of  phos- 
phoric acid  in  a  very  great  number  of  acute  and  chronic  diseases 
(having  made  above  1000  observations),  but  without  eliciting 
any  conclusions  capable  of  clinical  use.^ 

Ziilzer^  again  has  determined  the  amount  of  phosphoric  acid 
in  the  urine  in  relation  to  the  nitrogen  excreted.  He  finds  that 
in  ordinary  health  the  "  relative  amount"  of  phosphates  is  fairly 
constant  although  changed  somewhat  by  food,  as  mentioned 
above.  In  depressed  states  of  the  system,  however,  phosphates 
are  excreted  in  excess,  while  in  excited  states  they  are  dimin- 
ished. In  the  febrile  state  again  the  nitrogen  of  the  urine  is 
increased,  but  the  phosphates  are  diminished.  When  defer- 
vescence sets  in,  large  quantities  of  both  are  eliminated,  and 
during  convalescence  the  phosphates  predominate.  The  con- 
dition of  the  urine  in  cholera  was  found  to  be  peculiar.  That 
passed  in  the  early  stages  was  rich  in  phosphates,  while  as  the 
patient  recovered  the  phosphates  again  diminished.  Ziilzer 
also  found  an  increased  excretion  of  phosphates  after  injuries  to 
the  nervous  system. 

1  Medico-Chir.  Trans.,  vol.  xxxviii.  p.  261. 

*  Neubauer  and  Vogel  :  Analysis  of  the  Urine,  Syd.  Soc.  Trans,  p.  413 — 
where  the  reader  is  referred  for  fuller  information.  Dr.  Paton  found  that  mental 
work  caused  no  increase,  but  rather  a  diminution,  of  the  phosphates  in  the  urine. 
Journ.  of  Anat   and  Phys.,  May,  1871. 

3  Virch.  Arch.,  Bd.  66,  p.  223. 


FirosrHORic  acij)  and  the  phosphates.        117 

Salkowski,'  however,  objects  that  in  Ziilzer's  conclusiorm  suf- 
iicient  attention  was  not  paid  to  the  facts  that : 

1.  Phosphates  are  excreted  in  the  feces  as  well  as  in  the 
urine. 

2.  That  the  character  of  the  food  has  great  influence  on  the 
excretion. 

3.  That  the  bones  are  rich  in  phosplioric  acid,  and  they  pos- 
sibly take  some  part  in  the  metabolic  changes  which  occur  in 
the  body. 

To  the  practitioner,  therefore,  the  interest  of  phosphoric  acid 
and  the  phosphates  in  the  urine,  is  confined  to  the  earthy  phos- 
phates which  come  before  him  as  urinary  deposits  and  urinary 
concretions. 

Dr.  Prout  dignified  with  the  name  of  "phosphatic  diathesis," 
the  tendency  to  the  deposition  of  the  earthy  phosphates  in  the 
urine.  Dr.  Bence  Jones^  has,  however,  clearly  shown  that  this 
designation  is  wholly  inappropriate.  There  is  not  the  least 
reason  to  believe  that  there  is  any  constitutional  state  specially 
characterized  by  an  excessive  excretion  of  phosphates  ;  the  phos- 
phatic diathesis  of  Prout  is  simply  ammoniacal  urine.^ 

Deposits  or  Earthy  Phosphates. 

Phosphoric  acid  is  spontaneously  deposited  in  the  urine 
chiefly,  if  not  exclusively,  in  one  of  the  three  following  com- 
binations : 

1.  Amorphous   phosphate  of  lime,  or  bone-earth  (Ca3(PO^)2). 

2.  Crj^stallized  phosphate  of  lime  (CaHP0^+2Aq.). 

3.  Ammoniaco-magnesian  phosphate,  or  triple  phosphate 
(MgNH,P0,+6Aq.). 

These  three  compounds  are  occasionally  precipitated  together 
in  one  deposit;  much  more  frequently  the  first  and  third  are 
found  together,  forming  the  ordinar}^  sediment  of  ammoniacal 
urine.  This  latter  passes  under  various  names,  viz.:  "'the 
mixed  phosphates,"  the  "secondary  phosphates,"  or  "fusible 
matter."  This  will  come  under  notice  again  as  the  special  con- 
stituent of  secondary  calculous  formations. 

The  earthy  phosphates  are  readily  soluble  in  the  natural  acid 
of  the  urine;  but  are  insoluble  in  neutral  or  alkaline  fluids. 

Their  precipitation  as  deposits  is,  therefore,  properly  associated 
with  an  alkaline  state  of  the  urine;   it  is,  nevertheless,  a  fact 

1  Die  Lehre  vom  Harn,  p.  186. 

"^  Animal  Chemistiy,  p.  85. 

^  (Teissier,  of  Lyons,  has  described  certain  cases  under  the  title  of  "  Phosphatic 
Diabetes,"  which  are  characterized  bj"  polyuria  with  excessive  excretion  of  phos- 
phates, and  many  of  the  symptoms  of  ordinary  diabetes.  Dr.  Kalfe  (Lancet, 
Jany.  1881,  p.  406)  has  also  called  attention  to,  and  described  such  cases.  The 
affection,  however,  seems  to  have  great  affinities  with  Diabetes  Insipidus. — K.  M.) 


118  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

that  the  second  and  third  forms  are  occasionally  deposited  in 
urines  that  are  neutral  or  feebly  acid. 

Urines  depositing  the  earthy  phosphates,  or  tending  thereto 
by  their  neutral  or  feebly  acid  reaction,  become  turbid  when 
heated.  This  behavior  has  been  variously  explained.  Some 
have  thought  that  the  heat  expelled  the  carbonic  acid  v^hich 
held  the  earthy  phosphates  in  solution ;  others,  that  the  heat 
caused  rapid  decomposition  of  the  urea  into  carbonate  of 
ammonia,  and  thereby  suddenly  increased  the  alkalescence  of 
the  urine.  Scherer  thought  the  reaction  due  to  the  conversion 
of  the  neutral  phosphates  of  lime  and  magnesia  into  basic  salts. 
I  think  that  a  more  simple  explanation  may  be  offered.  Some 
salts  of  lime  (like  the  hydrate)  are  much  more  soluble  in  the 
cold  than  at  higher  temperatures.  This  is  probably  the  case 
with  the  lime  phosphates.  I  find  that  when  a  urine  which 
exhibits  this  reaction  is  heated  in  a  sealed  glass  tube  by  immer- 
sion in  hot  water,  the  turbidity  speedily  makes  its  appearance ; 
but  it  disappears  slowly  (either  wholly  or  partially)  after  the  tube 
has  cooled.  On  reheating  the  turbidity  returns,  and  again 
slowly  disappears  after  cooling.  This  experiment  may  be 
repeated  many  times  with  a  similar  result.  The  same  succession 
of  events  may  be  obtained  by  heating  the  urine  in  an  ordinary 
test-tube  over  the  open  flame,  provided  the  heating  be  not 
pushed  to  ebullition.  If  such  a  urine  be  sharply  boiled  there  is 
no  resolution  of  the  precipitate  after  cooling,  because  probably 
the  chemical  change  suggested  by  Scherer  has  been  brought 
about.  ^ 

1. — Amorphous  Phosphate  of  Lime,  or  Bone-earth. 

This  compound  is  invariably  precipitated  in  alkaline  urine. 
When  the  urine  is  alkaline  iTom  fixed  alkali,  this  is  the  ordinary, 
and  often  the  sole  deposit ;  but  far  more  frequently  it  is  accom- 
panied by  the  triple  phosphate. 

It  forms  an  amorphous,  whitish,  light  flocculent  deposit, 
indistinguishable  by  the  naked  eye  from  epithelium.  It  has  no 
affinity  for  the  coloring  matter  of  the  urine,  and  is  consequently 
of  a  paler  color  than  the  supernatant  urine,  differing  in  this 
respect  from  the  amorphous  urates.  The  surface  of  the  urine  is 
generally  covered  with  an  iridescent  film. 

The  application  of  heat  does  not  dissolve  the  deposit,  but,  on 
the  contrary,  increases  it.  A  drop  of  any  acid  causes  it  instantly 
to  disappear.  Under  the  microscope  it  appears  as  very  pale, 
minute  granules  in  irregular  clumps  or  patches,  much  resembling 
the  fawn-colored  lithates  {see  Fig.  3). 

^  For  another  explanation  of  this  reaction,  see  a  paper  bv  Prof.  Smith  in  the 
Dublin  Journ.  of  Med.  Sci.,  July,  1883. 


PHOSPHORIC    ACID    AND    TJIE    F II  OSP  Jf  A'I'ES, 


119 


Its  occurrence  depends  Bimj»ly  on  the  existence  of  an  alkaline 
reaction,  and  the  presence  of  lime  and  [)hosphoric  acid  in  the 
urine. 

This  is  the  normal  deposit  of  the  alkaline  urine  after  a  meal. 
It  is  also  frequently  seen  in  persons  whose  urine  has  heen  ren- 
dered alkaline  by  remedies  (carbonates,  acetates,  citrates  of  the 
alkalies,  etc.),  and  after  the  excessive  use  of  sweet  and  subacid 
fruits.  The  turbidity  caused  l>y  the  amori)hous  phosjdjate 
exists  in  its  greatest  intensity  at  the  moment  of  emission  of  the 
urine,  and  does  not  increase  on  cooling. 

The  clinical  significance-  and  treatment  of  this  deposit  are 
entirely  involved  in  those  of  alkaline  urine.  Bone-earth  alone 
very  rarely  constitutes  a  urinary  calculus;  but  it  enters  largely 
into  the  composition  of  phosphatic  calculi  in  combination  with 
the  ammoniaco-magnesian  phosphate. 

2. —  Crystallized  Phosphate  of  Lime,  or  Stellar  Phosphate. 

Dr.  Hassall  first  called  attention  to  the  existence  of  a  crystal- 
lized form  of  phosphate  of  lime  occurring  as  a  urinary  deposit. 

Ftg.  17. 


a- 


Stars  aud  rods  of  crystallized  phosphate  of  lime,  or  stellar  phosphate. 

In  1860  he  communicated  a  paper  to  the  Eoyal  Society  on  the 
composition  and  pathological  importance  of  the  calcareous 
phosphates  occurring  in  the  urine  as  a  spontaneous  deposit  of 


120  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

stellar  crystals.  He  considered  these  crystals  to  consist  of  bi- 
phosphate  of  lime ;  he  also  believed  them  of  far  graver  signifi- 
cance than  the  triple  phosphate  of  ammonia  and  magnesia. 

In  1861  I  had  an  opportunity  of  reexamining  this  question, 
and  published  the  results  of  my  observations  in  the  "  British 
Medical  Journal"  for  March  30,  1861. 

The  crystals  in  question  present  considerable  variety  of  form 
(Fig.  17). 

The  prevailing  appearance  is  that  of  crystalline  rods  or 
needles,  either  lying  loose  (d),  or  grouped  into  stars,  rosettes 
(a  a),  fans  (6),  or  sheaf-like  bundles  (c).  Some  of  the  crystals 
are  club  or  bottle-shaped  (e  e),  and  abundantly  marked  with 
lines  of  secondary  crystallization. 

In  a  case  of  diabetes  under  my  care  in  the  Manchester  Infir- 
mary, these  crystals  formed  a  constant  deposit.  The  urine  had 
been  brought  down  by  appropriate  treatment  to  fifty  ounces  a 
day,  and  the  patient  was  steadily  gaining  fiesh  and  strength. 
The  deposit  was  often  mixed  with  oxalate  of  lime,  and  some- 
times with  uric  acid ;  but  never,  except  as  the  result  of  putrefac- 
tive decomposition,  with  the  triple  phosphate.  I  managed  to 
collect  about  two  grains  of  the  crystals  in  a  pure  state,  and 
subjected  them  to  analysis.  The  results  indicated  the  following- 
formula :  2CaO,IIO,P05-f3IIO  (old  notation). 

By  adding  a  little  chloride  of  calcium  to  health}^  urine,  and 
reducing  its  acidity  to  near  the  neutral  point  with  caustic  soda, 
I  have  often  succeeded  in  obtaining  an  abundance  of  crystals 
closely  resembling  those  occurring  spontaneously  in  urine. 
The  reaction  of  the  urine  in  which  I  have  found  the  crystal- 
lized phosphate  of  lime  has  been  sometimes  faintly  acid,  more 
often  neutral,  or  alkaline. 

The  occurrence  of  a  deposit  of  the  stellar  phosphate  in  urine 
is  not  common.  It  is,  in  fact,  a  rare  deposit,  as  compared  with 
oxalate  of  lime,  uric  acid,  or  the  triple  phosphate.  The  presence 
of  this  deposit  in  quantity  is,  according  to  my  experience,  an 
accompaniment  of  some  grave  disorder.  In  addition  to  the 
case  of  diabetes  already  mentioned,  I  have  seen  the  stellar  phos- 
phates in  cancer  of  the  pylorus,  once  in  phthisis,  and  more  than 
once  in  patients  exhausted  by  obstinate  chronic  rheumatism. 
They  may,  however,  under  peculiar  conditions,  be  precipitated 
in  a  healthy  urine.  When  the  urine  is  rich  in  lime,  and  its 
acidity  is  at  the  same  time  depressed  to  near  the  neutral  line, 
stellse  of  phosphate  of  lime  may  form  quite  independently  of 
any  grave  disorder,  merely  as  the  result  of  a  coincidence  in  the 
chemical  composition  and  reaction  of  the  urine.  For  example, 
after  a  full  meal  the  acidity  of  the  urine  becomes  greatly 
reduced,  and  lime  derived  from  the  food  is  in  excessive  propor- 
tion.    In   such  circumstances,  I   have    several   times    detected 


PHOSPHORIC    ACID    AND    THE     IMl  OS  1' II  A '1' KS  . 


121 


stellffi  of  phosphate  of  liiiio,  hut  oiil_y  in  Hcanty  nurriherH.  A 
depressed  acidity  of  the  urine  is  an  essential  contingent  to  the 
formation  of  these  crystals ;  and  if  the  urine  suhsequently 
to  their  formation  increase  in  acidity,  they  may  spontaneously 
disappear. 

3. —  The  Phosphate  of  Ammonia  and  Magnesia,  or  Iriple  Phosphate. 

This  is  an  insoluhle  crystalline  compound,  which  occurs  very 
frequently  as  a  urinary  deposit  —  sometimes  alone,  but  much 
more  commonly  accompanied  with  the  amorphous  phosphate  of 
lime.  When  unmixed  with  any  other  substance,  the  deposit 
has  a  snow-white  appearance;  and  bright,  sparkling,  colorless 
crystals  are  observed  studding  the  sides  of  the  urine-glass  and 
forming  a  brilliant  crystalline  film  on  the  top.  The  ordinary 
form  of  the  crystals  is  a  triangular  prism  with  bevelled  ends. 
A  very  great  variety  of  subordinate  forms  is  produced  by  a 
planing  off  of  the  ridges  and  angles,  and  a  hollowing  out  of  the 
sides  (Fig.  18).     In  a  highly  anamoniacal  urine,  the  magnesian 

Fig.  18. 


lliffurent  formt!  of  triple  pbosphute  fryr>tals. 

phosphate  forms  elegant  dielytral  crystals,  which  appear  to 
arise  from  a  hollowing  of  the  sides  and  a  deep  notching  of  the 
extremities  of  the  prisms. 

The  triple  phosphate  is  easily  soluble  in  acids ;  yet  it  may  be 
found  in  urine  that  is  feebly  acid  to  test  paper.  Heat  does  not 
affect  it;  and  the  urine  which  deposits  it  commonly  becomes 
turbid  on  boiling. 


122  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

This  deposit  is  necessarily  present  in  ammoniacal  urine,  ex- 
cept in  the  very  rare  contingency  of  the  urine  not  containing 
any  magnesia.  When  urine  is  alkaline  from  fixed  alkali,  crys- 
tals of  this  salt  generally  appear  after  a  while.  This  is  easily 
explicable  after  the  demonstration  by  Neubauer  and  Heintz  that 
ammoniacal  compounds  exist  in  small  quantities  even  in  fresh 
natural  urine. 

In  the  immense  majority  of  cases  the  deposition  of  this  salt 
is  only  an  incident  due  to  the  loss  of  the  acid  reaction  of  the 
urine,  and  especially  of  ammoniacal  decomposition  of  the  urine. 
Occasionally,  however,  it  occurs  in  fresh  urine  which  is  neither 
decomposed  nor  sensibly  (to  the  smell)  ammoniacal.  The  fol- 
lowing is  the  most  remarkable  instance  which  I  have  witnessed  : 
J.  P.,  a  gentleman,  aged  twenty-nine,  of  a  moderately  healthy 
appearance,  but  irritable  temperament,  consulted  me  on  account 
of  a  sense  of  weakness  in  the  back  and  loins,  w^ith  general  de- 
bility and  languor,  and  a  tendency  to  sudden  perspirations  and 
fits  of  nervousness.  There  was  severe  smarting  at  the  close 
of  micturition.  He  had  suifered  from  gonorrhoea  three  years 
previously,  but  had  been  completely  free  from  any  urethral 
discharge  for  some  time.  The  urine  was  examined  on  several 
occasions.  It  was  faintly  acid  when  voided ;  and  deposited, 
sometimes  before  it  was  cold,  and  generally  within  a  couple  of 
hours,  an  abundant  precipitate  of  the  unmixed  ammoniaco-mag- 
nesian  phosphate.  The  annexed  note  was  taken  of  the  urine 
voided  at  11.30  a.  m.  on  January  28,  1861.  "  In  half  an  hour  it 
was  found  transparent,  perfectly  sweet  {i.  e.,  not  putrescent), 
faintly  acid ;  and  sparkling  crystals  of  the  triple  phosphate  could 
be  seen  floating  in  it.  At  four  p.  m.  the  same  day  the  specimen 
was  quite  clear;  brilliant  crystals  of  triple  phosphate  studded 
the  sides  of  the  glass,  and  at  the  bottom  was  collected  an  abundant 
snow-white  deposit  of  the  same  crystals.  The  urine  was  not 
albuminous,  neither  did  it  contain  pus  or  epithelium.  On  the 
following  day  the  specimen  continued  unchanged;  but  on  the 
fourth  day  the  reaction  had  become  faintly  alkaline ;  the  deposit 
was  losing  its  snow-white  character,  and  reddish  flakes,  com- 
posed of  spheres  of  urate  of  ammonia,  had  become  deposited. 
From  this  date  the  urine  began  to  decompose,  and  speedily 
became  ammoniacal  and  offensive. "  This  condition  of  the 
urine,  together  with  the  unpleasant  symptoms  before  noted, 
gradually  disappeared  in  the  course  of  six  weeks,  under  the 
influence  of  cold  sponging,  systematic  exercise  in  the  open  air, 
and  the  administration  of  dilute  nitric  acid  in  a  bitter  infusion. 

Stein^  found  a  deposit  of  magnesium  phosphate,  Mg3(P04)2, 
in  the  strongly  alkaline  urine  of  a  patient  suffering  from  dilata- 
tion of  the  stomach. 

1  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  18,  p.  207. 


CAREONATE    OF    LIME, 


123 


X.— CARBONATE  OF  LIME. 

When  urine  becomes  alkaline  from  carbonate  of  ammonia,  a 
small  quantity  of  carbonate  of  lime  is  precipitated  in  an  amor- 
phous condition  v/ith  the  earthy  phosphates.  I  have  only  seen 
it  in  a  crystalline  form  in  human  urine  when  voided  as  gravel 
or  small  calculi;  it  is  said  occasionally  to  occur  in  globular 
spheres  and  cornucopia-like  crystals  (Bird,  Trassall).  In  the 
alkaline  and  viscid  urine  of  the  horse,  carbonate  of  lime  is  fre- 
quently^ deposited  in  the  form  of  minute  spheres  composed  of 
radiating  linear  crystals  which  are  striking  objects  under  the 

Fro.  19. 


Spheres  and  diiinb-liells  of  carlioiiate  of  lime  from  the  nriue  of  the  horse 

microscope  {see  Fig.  19).  They  show  a  dark  cross  with  polar- 
ized light.  The  assumption  of  this  globular  form  is  probably 
connected  with  the  viscidity  of  the  urine. 

Carbonate  of  lime  constitutes  a  variety  of  urinary  calculus 
which  is  of  extreme  rarity  in  the  human  subject,  but  much 
more  common  in  the  herbivora  (see  Carbonate  of  Lime  Calculi). 


XL— SULPHURIC  ACID  AND.  THE  SULPHATES. 

About  thirty  grains  of  sulphuric  acid,  in  combination  with 
alkaline  bases,  are  daily  excreted  by  the  kidneys.  A  part  is 
derived  directly  from  the  food,  and  a  part  from  the  oxidation  of 
the  sulphur  contained  in  the  albuminous  compounds.  The  sul- 
phates are  highly  soluble,  and  in  only  two  cases  have  they  been 
known  to  constitute  a  spontaneous  urinary  deposit.^ 

1  Valentiner,  Ceiitralblat.  f.  Med.  Wissen,  1863,  p.  913;  Fiirbrinsier,  Deutsches 
Arch.  d.  klin.  Med.,  Bd.  20,  p.  511. 


124  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

In  all  febrile  states  sulphuric  acid  is  increased.  Dr.  Parkes 
has  observed  a  decided  increase  after  the  use  of  liquor  potassse. 
An  increase  is  also  observed  after  food,  and  in  all  conditions 
associated  with  an  intensilied  metamorphosis  of  tissue. 

It  has  not  yet  been  shown  that  a  knowledge  of  the  quantity 
of  sulphuric  acid  separated  by  the  kidneys  in  any  particular 
case  of  disease  is  capable  of  subserving  any  practical  purpose.^ 

XII.— CHLORINE  AND  THE  CHLORIDES. 

The  chlorides  never  form  spontaneous  deposits  in  the  urine ; 
and  the  variations  in  their  quantities  have  only  an  uncertain 
relation  to  special  states  of  disease,  but  depend  chiefly  on  the 
times  of  the  meals  and  on  the  general  rate  of  tissue-changes. 

A  good  deal  of  attention  has  been  called  to  the  falling  oft 
or  disappearance  of  the  chlorides  in  the  urine  in  acute  pneu- 
monia, and  their  reappearance  when  resolution  is  established. 
It  has  been  asserted  that  a  knowledge  of  the  amount  of  chlorides 
excreted  by  the  kidneys  in  the  course  of  this  disease,  furnished 
valuable  information  for  prognosis  and  treatment.  Later  obser- 
vations have,  however,  shown  that  the  indication  is  far  from 
being  a  reliable  one,  and  that  the  notions  entertained  in  some 
quarters  of  its  utility  are  greatly  exaggerated.  Although  it  be 
a  rule  of  very  prevalent  application,  that  the  chlorides  in  the 
increment  stage  of  acute  pneumonia  are  almost  completely  re- 
tained within  the  body,  and  that  their  reappearance  in  the  urine 
is  coincident  with  commencing  resolution,  yet  there  are  excep- 
tions to  both  these  statements,  especially  to  the  coincidence  of 
the  reappearance  of  the  chlorides  with  commencing  defer- 
vescence (see  Parkes). 

Supplementary  Remarks  on  the  Excretion  of  Phosphorus,  Sulphur, 

AND  Chlorine. 

These  three  elements  enter  largely  into  tjie  composition  of 
the  body,  and  they  are  abundantly  present  in  articles  of  food. 
They  pass  out  of  the  body  chiefly  with  the  urine ;  but  partly 
also  with  the  feces.  Multiplied  observations  have  been  made, 
and  continue  to  be  made,  on  the  rate  of  their  excretion  both  in 
health  and  disease;  and  important  ph^'siological  and  patho- 
logical deductions  have  been  drawn  from  these  investigations. 

1  (In  certain  rare  cases  sulphuretted  hydrogen  may  appear  in  the  urine.  In 
most  of  such  cases  there  has  been  found  either  some  communication  between  the 
intestinal  and  urinary  tracts,  or  a  pericsecal  abscess  from  which  the  gas  was 
absorbed.  Occasionally,  however,  neither  of  these  conditions  seems  to  have  been 
present,  and  the  origin  of  the  phenomenon  was  obscure.  See  a  case  by  Cameron, 
Lancet,  1880,  vol.  ii.  p.  766.     R.  M.) 


U  K  K  A  ,  ]  2o 

It  has  been  considered  tliat  the  rate  of  excretion  of  i)ho8|)lioru.s 
and  sulphur,  under  proper  precautions  and  corrections,  furnished 
a  measure  of  the  exchange  of  material  within  the  body — that  is, 
of  the  activity  of  the  molecular  life  of  the  tissues:  and  that  in 
disease,  an  important  insight  into  obscure  phenomena  could  be 
thus  obtained,  capable  of  being  turned  to  practical  uses.  In 
proportion,  however,  as  these  researches  have  been  extended,  it 
has  become  clearer  and  clearer  that  these  expectations  are  not 
likely  to  be  realized,  and  that  the  iDractitioner  is  not  likely  to 
draw  much  help  from  these  recondite  sources.  The  difficulties 
in  the  way  are  manifold.  In  the  iirst  place,  quantitative  deter- 
minations of  sulphur  and  phosphorus,  notwithstanding  all  the 
aid  of  modern  volumetrical  methods,  are  still  too  troublesome 
and  tedious  to  be  within  reach  of  any  but  a  very  select  body  of 
practitioners.  But  this  is  one  of  the  smallest  difficulties.  In 
all  such  determinations  it  is  necessary  to  do  more  than  ascertain 
the  proportion  per  cent.  To  obtain  results  of  any  value,  the 
quantity  per  day  must  be  ascertained.  Again,  there  are  physio- 
logical variations  to  make  allowance  for,  arising  from  food, 
exercise,  sleep,  etc. ;  and  thirdly,  it  has  now  been  ascertained 
that,  all  known  conditions  remaining  the  same,  the  rate  of  ex- 
cretion of  these  elements  presents  oscillations  from  an  unex- 
plained temporary  retention,  or  partial  retention,  of  the  ele- 
ments within  the  body,  which  is  succeeded,  after  a  shorter  or 
longer  interval,  by  a  compensating  increased  discharge.  These 
circumstances  render  it  necessary  to  continue  the  observations 
over  a  number  of  days — six  or  eight — in  order  to  cover  the 
inequalities.  For  these  and  other  reasons  which  might  be  men- 
tioned, these  inquiries  are  surrounded  with  difficulties.  It  is 
little  wonderful,  therefore,  that  the  results  obtained  by  diflerent 
experimenters  show  a  marked  want  of  uniformity :  and  it  is 
simply  the  fact  that,  from  a  clinical  point  of  view,  these  laborious 
investigations  must  at  present  be  regarded  as  unfruitful,  and  for 
that  reason  they  may  be  passed  over  with  only  a  slight  notice  in 
a  practical  work.  It  is  highly  desirable,  however,  that  researches 
of  this  class  should  be  pushed  on  ;  it  is  impossible  to  say  how 
soon  practical  lessons  maj^  be  culled  from  these  now  apparently 
dormant  facts.  At  any  rate,  they  cannot  fail  to  enlarge  our 
general  ideas  on  physiological  and  pathological  processes. 

XIII.— UEEA,  C0(NH2).,. 

Looking  at  the  urine  from  a  physiological  point  of  view,  urea 
must  be  regarded  as  its  most  important  constituent.  It  is  the 
chief  final  product  of  the  metamorphosis  of  the  albuminous 
tissues,  and  furnishes  the  form  under  which  nearly  all  the  nitro- 
gen finds  its  way  out  of  the. body. 


126  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

Urea  is  a  bland  crystalline  substance  possessing  the  properties 
of  a  feeble  base.  Its  best  known  combinations  are  the  nitrate 
and  oxalate,  both  of  which  are  much  less  soluble  than  urea 
itself.  Urea  is  very  soluble  both  in  water  and  alcohol ;  it  never 
forms  a  spontaneous  urinary  deposit.  Its  presence  in  a  urine  of 
high  density,  or  one  artificially  concentrated,  is  easily  demon- 
strated. If  to  such  a  urine  an  equal  volume  of  strong  nitric 
acid  be  added,  in  a  test-tube,  and  the  tube  be  plunged  into  cold 
water,  the  mixture  speedily  becomes  a  shining  mass  of  crystals 
of  nitrate  of  urea. 

The  daily  separation  of  urea  by  adult  men  between  the  ages 
of  twenty  and  forty,  averages  about  500  grains ;  but  the  amount 
varies  considerably  from  various  causes,  such  as  diet,  exercise, 
meteorological  conditions,  and  individual  peculiarities.  Of  the 
twenty-four  series  of  observations,  of  not  less  than  six  days  each, 
tabulated  by  Dr.  Parkes,  the  minimum  result  is  286.1  grains 
and  the  maximum  688.4  grains  per  day.  The  body-weight  has, 
as  might  have  been  expected,  a  very  apparent  relation  to  the 
daily  excretion  of  urea,  but  the  relation  is  not  simply  a  direct 
one,  because  the  weight  of  individuals  is  made  up  differently — 
some  being  heavy  from  bone  and  muscle,  others  from  an  ac- 
cumulation of  fat.  It  is  estimated  that  a  healthy  adult  man 
excretes  urea  at  the  daily  rate  of  3J  grains  per  pound  of  the 
weight  of  his  body. 

The  excretion  of  urea  is  greatly  increased  after  a  meal — espe- 
cially of  animal  food.  Bidder  and  Schmidt  believed  that  this 
arose  from  a  direct  transformation  into  urea  of  a  portion  of  the 
alimentary  materials  without  their  being  previously  fixed  as  tis- 
sues ;  but  Bischoff  and  Yoit,  with  more  probability,  attribute 
this  increase  to  an  accelerated  tissue-metamorphosis  induced  by 
the  presence  of  the  new  supplies  in  the  blood. 

Copious  water-drinking  causes  an  increased  separation  of 
urea.  Children  secrete  more  in  proportion  to  their  weight 
than  adults. 

The  immediate  effect  of  muscular  exercise  appears  to  be  to 
restrain  (or  at  least  not  to  increase)  the  excretion  of  urea ;  but 
it  is  increased  in  the  period  of  rest  which  follows  exercise.^ 

The  quantitative  estimation  of  urea  in  urine  may  be  made 
either  by  the  method  of  Liebig  or  by  that  of  Davy,  as  modified 
by  Drs.  Russell  and  "West. 

Liebig's  Volumetrigal  Method. — This  method  is  based  on 
the  property  of  urea  to  form  an  insoluble  precipitate  of  fixed 

1  For  further  information  respecting  the  excretion  of  nitrogen  (urea)  under 
various  conditions,  the  reader  is  referred  to  the  important  investigations  of  Dr. 
Parkes,  Med.  Time^  and  Gaz.,  1867,  I.  393,  and  Proc.  Roy.  Soc,  1871,  p.  849; 
also  Grfihaut,  J.  de  I'Anat.  et  Phys.,  1870,  318;  Weigelin,  Reichert's  Archiv, 
1868,  207;   Paton,  Journ.  of  Anat.  and  Phys.,  May,  1871. 


UREA.  1-7 

composition  with  the  nitrate  of  the  protoxide  of  mercury.  But 
in  order  that  the  test  may  operate,  it  h  necessary  to  free  the 
urine  beforehand  from  phosphates  and  sulphates.  It  is  also 
necessary  for  complete  accuracy  to  make  allowance  for  the 
chloride  of  sodium  present.  When  chloride  of  sodium  coexists 
in  any  fluid  with  urea-,  the  nitrate  of  mercury  produces  no  pre- 
cipitation of  urea  until  the  whole  of  the  chloride  of  sodium  is 
decomposed  with  formation  of  bichloride  of  mercury  and  nitrate 
of  soda.  After  this  conversion  is  completed,  urea  begins  to  be 
precipitated,  and  the  test-solution  is  to  be  added  until  no  more 
urea  remains  in  solution.  This  point  is  ascertained  by  a  solu- 
tion of  carbonate  of  soda,  which  immediately  develops  a  yellow 
color  when — and  not  before — all  the  urea  has  been  thrown  down 
with  the  mercury. 

Three  solutions  are  therefore  required. 

First.  A  baryta  solution,  to  precipitate  the  phosphates  and 
sulphates.  This  is  composed  of  one  volume  of  a  cold  saturated 
sokition  of  nitrate  of  baryta  mixed  with  two  volumes  of  satu- 
rated baryta-water. 

Second.  The  mercurial  test-solution.  Ten  cubic  centimetres 
of  this  solution  contain  0.772  gramme  of  red  oxide  of  mercury 
dissolved  in  nitric  acid — that  is  to  say,  in  the  form  of  nitrate  of 
the  peroxide  of  mercury. 

Third.  A  solution  of  carbonate  of  soda  of  about  the  strength 
of  twenty  grains  to  the  ounce. 

As  the  preparation  of  the  first  and  second  solutions  is  verj^ 
troublesome — the  latter  especially — it  is  more  convenient  to 
purchase  them  ready  made.^ 

The  analysis  is  performed  in  the  following  manner : 

1.  Forty  cubic  centimetres  (or  two  volumes)  of  the  urine  are 
mixed  in  a  beaker  with  tw^enty  cubic  centimetres  (one  volume) 
of  the  baryta  solution.  The  mixture  is  thrown  on  a  Alter; 
fifteen  cubic  centimetres  of  the  filtered  fluid  (which,  of  course, 
contains  two-thirds,  or  ten  cubic  centimetres  of  urine)  are  care- 
fully measured  oft"  and  placed  in  a  small  beaker. 

2.  A  graduated  burette  is  filled  with  the  mercurial  solution, 
which  is  then  very  carefully  dropped  into  the  beaker  until  the 
mixture  begins  to  become  turbid;  a  few  drops  generally  suffice. 
A  note  is  taken  of  the  quantity  of  the  solution  used  to  reach 
this  point:  it  indicates  that  all  the  chloride  of  sodium  is  decora- 
posed  and  that  the  urea  is  now  beginning  to  be  precipitated. 

3.  The  mercurial  solution  is  now  added  more  freely,  and 
thoroughly  mixed  by  means  of  a  glass  rod :  a  copious  white 

1  These  and  other  test-solutions  for  volumetrical  analyses  of  the  urine  may  be 
had  of  Griffin,  Bunhill  Eow,  London,  and  from  Mottershead  &  Co.,  Chemists, 

Manchester. 


128  CHEMICAL    CONSTITUENTS    OF    THE    URINE, 

precipitate  makes  its  appearance,  and  the  analysis  approaches 
completion. 

4.  This  point  is  ascertained  by  pouring  some  of  the  carbonate 
of  soda  solution  into  the  bottom  of  a  white  porcelain  plate ; 
and  taking  a  drop  from  the  turbid  mixture  in  the  beaker  by 
means  of  the  stirring-rod,  and  letting  it  fall  into  the  solution  on 
the  plate.  As  long  as  the  drop  produces  only  a  white  curdy 
circle  the  mercurial  solution  is  still  to  be  added;  but  as  soon 
as  a  yellow  tinge  appears  the  analysis  is  finished. 

5.  The  quantity  of  mercurial  solution  used  is  then  read  off, 
and  the  portion  used  before  the  occurrence  of  turbidity  sub- 
tracted— the  remainder  is  what  has  been  employed  to  precipitate 
the  urea.  Each  cubic  centimetre  of  the  solution  used  indicates 
0.154  grain  (or  0.01  gramme)  of  urea.  From  this,  by  an  easy 
calculation,  the  amount  of  urea  in  ten  cubic  centimetres  of  urine 
may  be  ascertained ;  and  if  the  number  of  cubic  centimetres  of 
urine  voided  in  the  twenty-four  hours  be  known,  the  daily  ex- 
cretion of  urea  is  readily  calculated. 

Davy's  Process  modified  by  Russell  and  West. — The  prin- 
ciple of  this  method  depends  on  the  decomposition  of  urea  by 
the  hypochlorites  and  hypobromites.  The  amount  of  urea  is 
determined  by  measuring  the  volume  of  nitrogen  evolved. 

A  solution  is  prepared  by  dissolving  100  grammes  of  solid 
caustic  soda  in  250  c.c.  of  water  and  adding  25  c.c.  of  bromine 
at  the  time  the  solution  is  required.^  The  apparatus  constructed 
by  Drs.  Russell  and  West  for  the  performance  of  the  analysis  is 
both  compact  and  cheap."  But  it  is  not  so  convenient  and  accu- 
rate to  work  with  as  that  devised  by  Mr.  Apjohn.  Mr.  Apjohn's 
apparatus  consists  of: 

1.  A  glass  measuring  tube  of  about  a  foot  in  length  drawn 
out  at  the  end  which  will  be  uppermost  when  the  tube  is  used, 
like  a  Mohr's  burette,  and  subdivided  into  30  parts  of  equal 
capacity,  the  aggregate  volume  of  which  is  55  c.c. 

2.  A  small  wide-mouthed  gas  bottle  of  about  60  c.c.  capacity. 
8.  A  short  test-tube   of  about  10  c.c.  capacity,  and  of  such 

height  that  when  introduced  into  the  gas  bottle  it  will  stand 
within  it  in  a  slightly  inclined  position. 

The  following  are  the  arrangements  for  combining  the  appa- 
ratus and  working  an  experiment : 

The  graduated  tube,  held  in  a  clamp  attached  to  a  retort- 
stand,  is  depressed  into  a  glass  cylinder,  nearly  tilled  with  water, 
until  the  zero  mark,  which  is  near  the  upper  end,  exactly  coin- 
cides with  the  surface  of  the  water.  15  c.c.  of  the  hypobromite 
solution  (100  grammes  of  ISTaHO,  250  c.c.  of  water,  25  c.c.  of 

1  Lancet,  February,  1876,  p.  241. 

2  It  may  be  had  from  Cetti,  Brooke  Street,  Holborn,  London,  price  8s.  6d. 


UREA, 


129 


bromine)  having  been  poui-ed  into  the  bottle,  the  test-tube  con- 
taining the  urine  is  introduced  by  nieariH  of  a  forceps,  care  being 
taken  that  none  of  its  contents  shall  spill  into  the  liypobromitc. 
The  tiask  is  now  closed  with  a  very  accurately  fitting  India- 
rubber  stopper,  perforated  with  a  hole  in  which  is  inserted  a 
short  piece  of  glass  tubing  open  at  both  ends,  and  is  then  con- 
nected with  the  measuring  tube  by  means  of  a  piece  of  elastic 
tubing.     It  is  now  inclined  so  as  to  allow  the  urine  to  mix  with 


Fig.  20. 


Apjohn's  apparatus  for  the  estimation  of  urea  with  Kussell  and  West's  sohition. 

the  hypobromite.  Effervescence  at  once  commences,  and  as  it 
proceeds  the  measuring  tube  is  gradually  raised  so  as  to  relieve 
the  disengaged  nitrogen  from  the  hydrostatic  pressure.  The 
flask  is  shaken  a  few  times,  and  when  the  reaction  is  completely 
over,  the  apparatus  is  left  for  a  few  minutes  until  it  has  acquired 
the  temperature  of  the  room  in  which  the  experiment  is  per- 
formed. Another  exact  levelling  of  the  measuring  tube  is 
made,  and  the  number  of  the  division  corresponding  to  the 
volume  of  the  developed  nitrogen  is  read  oif. 

The  tube  is  so  graduated  that,  when  5  c.c.  of  urine  are  oper- 
ated on,  each  division  corresponds  to  0.1  per  cent,  of  urea,  or 
0.44  grain  pier  fluidounce  of  the  British  Pharmacopoeia.  An 
easy  calculation  from  these  data  gives  the  daily  discharge  of 
urea.  Suppose  45  ounces  of  urine  are  voided  in  the  24  hours, 
and  that  5  c.c.  of  this  evolve  20  measures  of  nitroo'en  with  the 
hypobromite  solution,  then : 

0.44X20X40  =  896. 

The  daily  discharge  of  urea  was  396  grains. 

9 


130  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

I  have  carefully  tested  this  method  and  have  found  it  easy, 
accurate,  and  speedy.^ 

Pathological  Relations  of  Urea. — The  excretion  of  urea  in 
disease  has  been  examined  in  a  large  number  of  cases.  In  the 
acute  stage  of  febrile  and  inflammatory  diseases,  there  is  an 
increased  formation  and  discharge  of  urea,  depending  on  an 
accelerated  metamorphosis  of  tissue.  When  the  crisis  of  the 
disorder  has  passed,  and  defervescence  sets  in,  the  excretion  of 
urea  falls  even  below  its  natural  average.  This  rule,  however, 
is  liable  to  exceptions ;  it  appears  that  in  not  a  few  instances 
there  is  a  retention  of  urea  within  the  body  during  the  pyrexial 
period,  even  when  no  disorder  of  the  kidneys  exists,  and  a  com- 
pensating discharge  when  convalescence  begins.  Acute  (inflam- 
matory) Bright's  Disease  is  a  constant  exception ;  the  urine  in 
that  complaint  is  poor  in  urea ;  but  this  arises,  not  from  dimin- 
ished formation,  but  from  defective  separation,  owing  to  the 
blocked-up  condition  of  the  uriniferous  tubes. 

Frerichs  found,  in  one  example  of  acute  yellow  atrophy  of 
the  liver,  a  total  deficiency  of  urea  in  the  urine ;  in  a  second  case 
there  was  abundance  of  urea  in  the  urine  discharged  during 
life,  but  only  a  trace  in  that  withdrawn  from  the  bladder  after 
death. 

In  chronic  diseases  not  involving  the  kidneys,  the  excretion 
of  urea  has  not  usually  been  found  materially  aftected. 

In  saccharine  diabetes  there  is  an  excessive  separation  of  urea, 
as  might  have  been  expected  from  the  accelerated  rate  of  tissue 
metamorphosis  which  must  accompany  the  full  feeding  and 
rapid  emaciation  of  these  patients. 

In  a  case  of  diabetes  insipidus  (with  a  daily  discharge  of  12 
or  14  pints  of  urine),  I  found  the  excretion  of  urea  to  oscillate 
between  394  and  505  grains  daily,  which  yielded  a  mean  rate 
of  4J  grains  per  pound  of  the  body-weight.  This  is  about  a 
fourth  above  the  average  for  healthy  individuals. 

In  both  acute  and  chronic  degeneration  of  the  kidneys 
(Bright's  Disease)  there  is  a  marked  lessening  of  the  excretion 
of  urea,  as  will  be  more  fully  commented  on  when  those  diseases 
come  to  be  described.  The  proportion  of  urea  is  also  greatly 
reduced  in  the  urine  voided  by  persons  sufi'ering  from  an 
obstruction  in  the  ureters  {see  Suppression  of  Urine). 

One  of  the  most  important  properties  of  urea  is  the  great 
facility  with  which  it  is  broken  up  and  resolved  into  new  com- 
pounds. This  property  comes  into  important  play  when  urea 
is  unnaturally  retained  in  the  blood  or  in  the  urinary  passages. 

1  For  a  further  account  of  this  method,  see  Eussell  and  West's  paper,  Journ.  of 
Chem.  Soc,  Aug.  1874;  and  Practitioner,  Feb.  1875.  Apjohn's  paper  is  in  the 
Chemical  News,  Jan.  22,  1875. 


UKJOA.  131 

It  has  been  already  explained  with  wliat  conHequoDccs  tliis 
bland  and  innocuous  base  is  converted  into  punii;ent  carbonate 
of  ammonia  in  the  bladder  and  other  parts  of  the  urinary 
tract.  A  similar  conversion,  taking  place  in  the  blood,  was 
believed  by  Frerichs  to  be  the  cause  of  the  stormy  and  dan- 
gerous phenomena  of  urfemia. 

Dr.  Prout  believed  that  there  existed  a  peculiar  morbid  state 
characterized  by  an  absolute  and  relative  increase  of  the  excre- 
tion of  urea,  unaccompanied  by  pyrexia.  To  this  condition 
Dr.  Willis,  who  adopted  the  view  of  Prout,  gave  the  name  of 
Azoturia.  The  subjects  of  this  form  of  disease,  according  to 
Prout,  had  usually  a  frequent  and  urgent  desire  to  pass  water 
both  by  night  and  day.  This  seemed  principally  due  to  an  irri- 
table sensation  referred  to  the  neck  of  the  bladder,  occasionally 
extending  along  the  urethra;  but. in  some  cases  it  was  due,  at 
least  in  part,  to  real  diuresis.  In  almost  every  instance  the 
quantity  of  urine  voided  in  the  twenty-four  hours  was  somewhat 
above  the  natural  standard.  The  quantity  was  also  particularly 
liable  to  be  increased  by  causes  which  would  scarcely  affect  a 
person  in  perfect  health,  at  least  to  the  same  degree ;  such  as  by 
a  chilly  state,  mental  emotion  or  excitement,  etc.^ 

In  addition  to  the  direct  urinary  symptoms,  there  was  some- 
times a  sense  of  weight  or  dull  pain  in  the  back,  accompanied 
by  disinclination  to  bodily  exertion ;  there  was  no  remarkable 
thirst;  nor  craving  for  food;  nor  emaciation.  Moreover,  the 
functions  of  the  skin  appear  to  be  little  deranged. 

Such  is  a  summary  of  the  description  of  Prout.  He  does  not 
supply  any  details  as  to  the  daily  flow  of  urine  nor  the  daily 
amount  of  urea.  At  the  time  Prout  wrote,  very  little  was  known 
as  to  the  natural  (physiological)  variations  in  the  excretion  of 
urea;  and  the  opinion  he  held  as  to  urea  being  chiefly  the  final 
product  of  the  metamorphosis  of  the  gelatinous  tissues  has  since 
been  proved  to  be  erroneous.  Looking  at  the  question  from 
the  standing-point  of  the  physiological  doctrines  now  in  the 
ascendant,  it  is  difficult  to  admit  the  existence  of  a  condition 
characterized  by  the  incompatible  coincidences  of  .an  increased 
excretion  of  urea,  with  absence  of  thirst,  absence  of  excessive 
feeding,  and  absence  of  emaciation. 

Precise  facts  in  support  of  Prout's  view  are  wanting.  Willis's 
description  is  too  loose  to  give  much  confidence,  and  subseque"nt 
writers  have  contented  themselves  with  a  reference  to  Prout 
and  Willis.^ 

1  Prout:  Stomach  and  Kenal  Diseases,  5th  edit.,  p.  97 

^  The  six  cases  recorded  by  Dr.  Handfield  Jones,  in  the  Brit.  Med.  Journ.  for 
Oct.  12,  1861,  under  the  title  of  "  Cases  of  Baruria,"  are  so  deficient  in  necessary 
details,  that  they  are  of  no  service  to  a  reader.  In  only  one  of  them  was  the 
urine  of  the  twenty-four  hours  collected  and  examined,  and  in  that  case  only  on 
one  occasion.  In  the  remainder  "  baruria  "  seems  to  have  been  inferred  to  exist 
from  the  high  density  of  a  single  specimen. 


132  CHEMICAL    CONSTITUENTS    OF    THE    URINE. 

Dr.  Parkes/  however,  records  a  remarkable  case  examined  by 
Dr.  Kiiiger.  The  patient  was  a  middle-aged  man  weighing  109 
pounds,  who  was  not  feverish,  and  appeared  only  feeble.  He 
was  fed  on  the  ordinary  diet  of  the  hospital  (University  College), 
and  passed  in  each  twenty-four  hours  no  less  than  1130  grains 
of  urea  (mean  of  twelve  days),  or  10.36  grains  to  each  pound 
avoirdupois  of  his  body-weight.  There  was  a  trace  of  sugar, 
but  not  enough  to  determine  quantitatively.  The  daily  flow  of 
urine  in  this  case  amounted  to  96  fluidounces,  which  is  fully 
double  the  normal  average. 

In  my  own  experience,  I  have  usually  found  that  cases  which 
at  first  sight  appeared  to  belong  to  this  category — cases  exhibiting 
a  dense  urine  and  a  train  of  nervous  symptoms — turned  out  on 
more  exact  investigation  to  want  the  special  feature  indicated 
by  Prout  as  the  essential  one ;  namely,  an  absolute  increase  in 
the  daily  discharge  of  urea,  l^evertheless,  some  facts,  rarely 
observed,  have  left  an  impression  on  my  mind  that  Prout's  de- 
scription is  not  altogether  fanciful.  The  following  case,  which 
I  saw  with  the  late  Mr.  Greaves,  of  this  town,  seems  to  have 
been  one  of  those  Prout  had  in  view  when  he  drew  up  his 
account. 

Mr.  L.,  a  man  about  50,  complained  of  troublesome  irritation  at  the 
back  of  the  pharynx,  debility,  want  of  energy  and  power  of  application 
to  business.     In  the  preceding  three  months  he  had  lost  20  lbs.  in  weight. 

The  urine  was  first  examined  by  me  on  May  23, 1863.  It  had  sp.  gr. 
1029,  and  contained  a  small  quantity  of  sugar,  but  less  than  one  grain  to 
the  jfluidounce.  This  was  the  only  occasion  on  which  I  detected  sugar, 
but  Mr.  Greaves  had  found  it  once  or  twice  previously.  It  was  arranged 
that  the  whole  of  the  urine  voided  in  each  24  hours  should  be  separately 
collected  and  sent  to  me  for  analysis.  This  was  done  for  three  succes- 
sive days ;  and  three  weeks  later  it  was  done  again  for  two  successive 
days.     The  following  table  exhibits  the  result  of  the  examination : 


Quantity 

per 

clay. 

Sp.  gr. 

Total  urea. 

May  25 . 

.     27    ounces 

1029.5 

542  grains 

"26. 

.     80i 

11 

1029.75 

559       " 

",    27. 

.     31" 

11 

1028.25 

555       " 

June  18 . ■ 

.     29 

u 

1027.5 

565       " 

"19. 

.     34 

u 

1020.5 

510       " 

This  patient  was  not  febrile ;  his  weight  was  120  lbs.;  there  was  little 
appetite,  and  no  thirst,  and  yet  he  excreted  daily  4.6  grains  of  urea  for 
each  pound  of  body-weight  on  these  five  days,  which  is  fully  a  quarter 
beyond  the  usual  average.  I  saw  the  patient  again  towards  the  end  of 
January,  1863.  The  urine  had  then  lost  its  peculiarity;  and  the  health, 
under  a  regulated  diet  and  exercise,  and  a  course  of  vegetable  tonics, 
with  citrate  of  potash,  had  become  completely  reestablished. 

^  Parkes :  On  the  Composition  of  the  Urine,  p.  374. 


UREA.  133 

Prout  was  of  opinion  that  thcRC  cafies  were  patholoii^ically  re- 
lated to  diabetes ;  and  he  conjectured,  though  he  had  not  wit- 
nessed the  fact,  that  they  often  developed  subsequently  into  that 
disease.  That  there  is  some  relation  between  the  two  con- 
ditions seems  not  improbable;  in  the  cases  of  Dr.  Ringer  and 
myself  a  small  quantity  of  sugar  was  temporarily  present  in  the 
urine  with  the  excess  of  urea.^ 

In  the  case  just  related  the  cause  of  the  complaint  was  mental 
anxiety;  and  in  all  the  instances  which  I  have  been  inclined  to 
place  in  this  group,  the  origin  of  the  disorder  could  always  be 
traced  to  some  kind  of  mental  emotion. 

1  See  Demange,  These  de  Parif=,  1878,  and  London  Medical  Kecord,  1879,  p.  98. 


CHAPTER   lY. 

ABNORMAL  SUBSTANCES  IN  THE  UBINE:   OBGANIC 
DEPOSITS. 

I.— EXTEA-EENAL  EPITHELIUM. 

Any  part  of  the  genito-uriimry  passages  may  shed  its  epi- 
thelium into  the  urine  so  as  to  form  a  sediment. 

The  urine  of  the  two  sexes  difiers  notably  in  the  character 
and  quantity  of  the  epithelial  cells  found  therein.  This  arises 
from  anatomical  differences  in  the  lower  genito-urinary  passages; 
and  advantage  may  sometimes  be  taken  of  this  circumstance  to 
distinguish  the  sex  of  the  individual  whose  urine  is  under 
examination. 

In  the  male  sex  an  epithelial  depositof  extra-renal  source  is 
most  commonly  derived  from  the  urethra  and  prostate  gland, 

Fig.  21. 


Oval  and  tailed  epithelial  cells,  found  in  the  thready  and  flaky  deposit  of  the  urine  of  a  man  who 
had  formerly  suffered  from  gonorrhoea. 

and  is  composed  of  oval,  tailed,  or  rounded  cells  (Fig.  21),  about 
twice  as  large  as  pus  cells  and  usually  flattened,  A  deposit  of 
this  sort  is  always  scantj^  and  to  the  naked  eye  presents  the 


E  X  T  R  A  -  R  E  N  A  L    E  P 1 T  H  K  L 1 U  M 


135 


a|)pearance  of  a  collection  of  whitish  flakes  and  strings.  When 
taken  up  by  the  pipette  for  examination,  these  flakes  are  found 
to  have  the  viscid  glairy  character  of  mucus.  A  sediment  of 
this  character  is  not  uncommon  in  men;  in  many  cases  it  may 
be  distinctly  traced  to  an  old  gonorrlirjca,  which  has  long  since 
passed  away  leaving  no  other  vestiges  behind  it.  The  deposits 
found  in  the  urine  of  persons  subject  to  nocturnal  emissions 
have  very  much  the  same  appearance  to  the  naked  eye. 

It  is  well  to  be  aware  of  the  nature  of  this  deposit.  Youths 
principally,  but  older  men  not  unfrequently,  observe  for  them- 
selves the  presence  in  their  urine  of  the  strings  and  flakes  just 
described;  and  they  are  liable  to  become  subject  to  hypochon- 
driacal fears  and  anxiety  respecting  them.  Such  individuals 
are  common  victims  of  unprincipled  empirics.     I  was  recently 

Fig.  22. 


Tugiual  epithelium  in  the  urine. 

consulted  by  a  gentleman  who  paid  very  large  sums  to  a  quack 
who  had  persuaded  him  that  the  flaky  shreds  in  his  urine — the 
innocuous  vestiges  of  a  gonorrhoea  contracted  live  years  pre- 
viously— were  of  a  dangerous  nature,  and  required  active  and 
long-continued  treatment.  It  is  not  a  trifling  matter  to  be  able 
to  allay  the  alarm  of  such  patients,  and  to  convince  them  that 
the  subject  of  their  anxiety  is  wholly  unimportant. 

In  females,  epithelial  sediments  are  both  common  and  abund- 
ant. From  the  simple  short  urethra  the  urine  receives  little 
or  nothing ;  but  the  vaginal  membrane  is  throughout  invested 


136 


ABNOEMAL    SUBSTANCES    IN"    THE    URINE, 


with  a  lining  of  pavement  epithelium,  the  elements  of  which  are 
detached  with  facility  and  in  great  quantity,  giving  rise  to  an 
abundant  arnorphous-looking,  light,  cloudy  deposit  in  the  urine. 
"When  examined  microscopically  this  deposit  is  found  composed 
of  large  flat  cells,  resembling  the  epithelia  of  the  mouth  (Fig. 
22).  The  cells  either  lie  discrete,  or  united  by  their  borders 
into  patches  of  rude  mosaic. 

A  deposit  of  this  character  is  found  only  in  the  urine  of  females, 
and  comparatively  few  are  wholly  exempt  from  it.  In  the  sub- 
jects of  vaginal  leucorrhcea  it  is  always  abundant;  but  it  is  also 
present  frequently,  and  in  quantity,  where  there  is  no  appreci- 
able disorder  of  the  genital  passages.  Even  young  (female)  chil-^ 
dren  may  have  a  sedimentary  urine  from  this  cause,  especially 
those  of  a  strumous  habit. 

The  epithelium  of  the  bladder,  ureter,  and  pelvis  of  the  kid- 
ney finds  its  way  into  the  urine  of  both  sexes  in  cases  of  vesical 
calculus,  renal  calculus,  and  pyelitis  from  any  cause.     The  epi- 

Fm.  28. 


Epithelial  cells  from  the  bladder,  ureter,  and  pelvis  of  the  kidney. 


thelium  which  lines  these  parts  is  of  a  transitional  character, 
and  presents  a  great  variety  of  forms  —  cylindrical,  spindle- 
shaped,  caudate,  oval,  spheroidal,  and  irregular  (Fig.  23).  It 
cannot  fail  to  be  noticed  how  like  some  of  these  cells  are  to 
cancer-cells ;  so  like,  indeed,  that  the  recognition  of  cancer-cells 
(as  such)  in  the  urine  becomes  a  matter  of  very  great  uncer- 
tainty. In  cases  of  suspected  pyelitis  the  existence  of  cells  of  this 
class  in  the  urine  greatly  fortifies  the  diagnosis.     {See  Pyelitis.) 


RENAL    EPITHELIUM    AND    CASTS    OF    TUBES, 


137 


II.— EENAL  EPITHELIUM  AND  CASTS  OF  TUI5P:S;  THE  T^EPOSITS 
ASSOCIATED  WITH  ALBUMINUIUA. 

As  renal  epithelium  and  casts  of  the  uriniferous  tubes  are 
commonly  found  together,  it  will  be  convenient  to  consider 
them  in  conjunction. 

The  uriniferous  tubes  are  liuud  with  a  single  layer  of  e}jithe- 
lium.  The  cells  of  this  layer  in  the  cortical  part  of  the  kidney 
consist,  in  the  healthy  state,  of  a  round  or  slightly  oval  nucleus 
having  a  delicate,  regular  outline,  resembling  closely,  both  in 
size  and  asj^ect  (except  in  not  ])eing  biconcave),  the  red  corpuscle 
of  the  blood ;  around  this  nucleus  is  aggregated  a  quantity  of 
solid,  yet  friable,  faintly  granular  substance  (Fig.  24,  a).     A 


Pig.  24. 


Kenal  epitlielium      <f'.,^faral  appearance  ;   6.  Atrophied  and  disintegrated  renal  cells ;  c.  Kenal 
cells  in  a  state  of  fatty  degeneration. 

distinct  cell-wall  is  usually  understood  to  exist  around  each 
nucleated  mass ;  but  my  own  observations  tend  to  support  the 
view  of  Dr.  Beale,  that,  in  the  convoluted  tubes,  a  distinct  cell- 
wall  can  only  occasionally  be  seen.  "When  the  cut  surface  of  a 
healthy  kidney  is  scraped,  the  nucleated  masses  are  freely  sepa- 
rated from  each  other.  The  nucleus  itself  is  then  seen  to  be 
exceedingly  uniform  in  size  and  shape;  but  the  granular  matter 
surrounding  it  is  very  irregular.  Sometimes  the  nucleus  is 
quite  free ;  more  commonly  it  is  embedded  in  granular  matter. 
Sometimes  this  latter  forms  a  spheroidal  mass,  with  a  more  or 
less  distinct  cell-wall ;  sometimes  the  granular  mass  looks  as  if 
partly  broken  oif;  or  there  remains  only  a  small  quantity  of  it 


138  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

adhering  to  the  nucleus.  In  the  straight  tubes  the  cell-wall  is 
always  distinct  enough,  and  the  cells  are  flatter,  so  that  the 
available  bore  of  the  tubes  is  larger  in  the  pyramidal  than  in 
the  cortical  portions.  When  there  is  rapid  proliferation  of  the 
epithelium  of  the  uriniferous  tubes  (as  in  the  large  white  or 
mottled  kidney)  the  nucleus  is  frequently  seen  cleft  into  two  or 
three  nucleoli,  and  the  cell  puts  on  the  appearance  of  a  pus 
corpuscle. 

The  epithelial  lining  of  the  uriniferous  tubes  is  liable  to  be 
separated  from  the  basement  membrane,  in  certain  diseased 
conditions,  and  discharged  with  the  urine.  Coagulable  matter 
is  also  liable  to  be  poured  into  the  uriniferous  tubes,  and  having 
solidified  there  is  afterwards  washed  out  by  the  stream  of  urine, 
and  appears  therein  as  casts  or  moulds  of  the  tubes. 

The  epithelium  and  casts  thus  discharged  present  a  number 
of  modifications  of  form  and  aggregation,  which  serve  to  indi- 
cate and  distinguish  particular  states  of  disease  in  the  kidneys. 

Renal  epithelium,  forming  a  urinary  deposit,  occurs  usually 
in  scattered  patches ;  but  in  the  acute  form  of  Bright's  disease 
the  epithelium  is  detached  in  coherent  pieces,  which  constitute 
casts  of  the  entire  lumen  of  the  tubes.  These  are  "the  epithe- 
lial casts"  to  be  presently  mentioned.  The  cells  never,  per- 
haps, preserve  perfectly  their  normal  form.  The  most  common 
change  is  a  greater  or  less  disintegration  or  breaking  up  of  the 
cells  into  amorphous  granular  matter,  which  readily  takes  place 
from  the  absence  or  extreme  tenuity  of  the  cell-wall.  The  cells 
also  become  atrophied  (Fig.  24,  6);  and  not  unfrequently  degen- 
erated into  fatty  corpuscles  (c),  which  are  significant  of  changes 
in  the  kidney  of  most  serious  nature. 

Casts  of  the  Uriniferous  Tubes. — Casts  of  the  uriniferous 
tubules,  composed  of  a  fibrinous  material,  are  often  found  in 
the  urine,  and  are  of  great  importance  in  the  semeiology  of 
renal  disease.  As  a  rule  they  are  associated  #i"l;!h- albuminuria, 
but  they  are  occasionally  detected  when  the  uftnW^oes  not  con- 
tain any  albumen  discoverable  by  our  ordinary  tests.  Tube-casts 
present  the  following  varieties  : 

1.  Epithelial  Casts  (Fig,  25,  a  a). — These  consist  of  a  cylinder 
of  coagulable  matter,  studded  over  with  epithelial  cells  which 
adhere  thereto  and  are  partly  embedded  therein.  Some  epi- 
thelial casts  seem  to  be  entirely  composed  of  amalgamated 
epithelial  cells. 

2.  Opaque  Granular  Casts  (Fig.  25,  b  b). — These  have  a  dark 
coarsely  granular  appearance,  and  are  generally  of  medium  size 
(tfo'  ^f  ^^  inch  in  diameter). 

3.  Transparent  or  Waxy  Casts  (Fig.  26).  —  These  are  clear, 
glassy,  fibrinous  cylinders,  sometimes,  so  transparent  as  to  be 
invisible  until  tinted  artificially  by  means  of  iodine  or  a  solu- 


RENAL    EPITHELIUM    A  N  J>    CASTS    OF    'J'UJiKS. 


]'6'.) 


tiou  of  magenta;  sometimes  faint  markings  map  their  surface, 
or  they  show  a  faint  molecular  composition.  They  present 
extreme  differences  of  diameter;  the  smallest  are  not  more  than 
the  breadth  of  a  blood  corpuscle  {a  a) ;  the  largest  are  ^.J,-,-,  of 
an  inch,  or  more,  in  breadth  ibhc);  others  again  are  mediiirn 
sized.' 

Fig.  25. 


a  a.  "Epithelial' 


i<ts.     hb.   "Opaque  gianuliii      cists,  fiuni 


'  uf  acute  Bright's  disease. 


4.  Fatty  Casts  (Fig.  27,  a  a). — Sometimes  a  transparent  cast 
is  studded  with  tolerable  uniformity  with  minute  oil  particles; 
more  commonly  the  oily  particles  are  irregularly  distributed 
in  and  on  such  a  cast;  sometimes  again  they  are  collected 
into  dark  botryoidal  masses  —  apparently  the  result  of  the 
breaking  up  of  an  adherent  cell  which  has  undergone  fatty 
degeneration. 

5.  Blood  Casts  (Fig.  27,6  6). —  Sometimes  these  are  exceed- 
ingly beautiful  objects,  being  perfect  cylinders  composed  of 
delicate  circles  placed  in  apposition  ;  more  generally  a  fibrinous 
cast  is  studded  irregularly  with  blood-corpuscles,  some  perfect, 
and  some  withered  and  contorted;  sometimes  the  cast  seems 
composed  of  blood-disks  crushed  or  compressed  into  a  cylin- 
drical mould  (c). 

6.  Pus  Casts. — Dr.  G.  Johnson  has  described  and  figured 
moulds  or  casts  of  the  uriniferous  tubes  composed  of  pus  cor- 
puscles.    In  two  such  cases,  examined  post  mortem,  he  found 


1  Bartels  has  described  an  amyloid  change  occasionally  found  in  these  casts. 


140 


ABNORMAL    SUBSTANCES    IN    THE    URINE, 


multiple   abscesses   in  the   kidneys.     In  a  case  examined   by 
myself,  where  both  kidneys  were  riddled  with  myriads  of  sec- 


FiG.  26. 


Waxy  casts,  a  a.  Erom  the  iirine  of  a  man  with  chronic  Bright's  disease  of  eight  months'  duration 
(urine  bloody,  intensely  albuminous,  anasarca,  dying  from  pneumonia) ;  6  6.  From  a  case  of  chronic 
IJright's  disease  (large  white  kidney) ;  c.  From  a  case  of  chronic  Bright's  disease  (contracted  kidney 
with  fatty  degeneration) . 

Fig.  27. 


a  a.  Fatty  casts;  6  6.  Blood  casts  ;   dd.  Free  fatty  molecules. 

ondary  abscesses,  the  urine  found   in  the  bladder  after  death 
contained    no   recos^nizable   tube-casts ;    the    observation   was, 


RENAL    EPITHELIUM    AND    CAHTS    OF    TUBES.  141 

however,  an  imperfect  one,  owing  to  cornrnenciTig  arnmoniacal 
decomposition  of  the  urine,  which  may  have  caused  disintegra- 
tion of  any  preexisting  casts. 

The  basis  material,  or  substratum  composing  tube-casts,  was 
supposed  by  Ilenle  to  be  coagulated  blood-fibrin.  This  is  prob- 
ably true  with  regard  to  blood  casts,  and  the  recent  researches 
of  Weissgerber  and  Perls,^  Posner,^and  Kibbert^  tend  to  support 
the  view  that  hyaline  casts  may  be  formed  in  this  fashion,  and 
that  possibly  the  disintegration  of  leucocytes  may  play  some 
part  in  causing  the  coagulation.  But  the  investigations  of  Axel 
Key  and  Langhans^  have  made  it  probable  that  many  hyaline 
and  granular  casts  are  otherwise  composed.  According  to  these 
investigations,  most  tube-casts  are  formed  by  fusion  and  dis- 
integration of  cells  which  have  escaped  into  the  lumen  of  the 
uriniferous  canals.  These  cells  may  be  desquamated  epithelial 
cells,  leucocytes,  or  blood-disks.  In  the  canals,  the  disintegrated 
material  is  moulded  into  cylinders,  and  may  then  undergo  fur- 
ther changes,  becoming  transparent  or  finely  granular;  some 
casts  are  also  to  be  regarded  as  a  secretion  product  of  the  epi- 
thelial cells  lining  the  tubules.  CorniP  has  observed  hyaline 
globules  in  the  epithelial  cells,  which  are  extruded  into  the 
lumen  of  the  tube  and  combine  to  form  casts.  In  their  passage 
through  the  low^er  renal  tubes  the  casts  may  undergo  various 
alterations  in  form. 

To  the  naked  eye  deposits  of  renal  epithelium  and  tube-casts 
appear  amorphous ;  they  are  often  very  scanty,  and  resemble  a 
cloud  of  mucus ;  sometimes  they  are  more  dense  and  form  a 
white  flour-like  sediment. 

Clinical  Significance  of  Eenal  Epithelium  and  Tube- 
casts. — The  most  general  inference  from  the  presence  of  these 
bodies  in  the  urine,  is  the  existence  of  some  serious  disorder  in 
the  kidneys.  But-  a  study  of  their  various  forms  and  appear- 
ances furnishes  still  further  information  of  great  weight  in  the 
diagnosis  and  prognosis  of  the  different  stages,  and  difierent 
types  of  renal  disease.  This  subject  cannot,  however,  be  advan- 
tageousl}'  considered  in  the  p)resent  section,  but  will  take  its 
place  more  appropriately  in  the  chapters  on  Bright's  disease 
and  congestion  of  the  kidneys.  The  following  general  remarks 
may,  however,  find  room  here : 

1.  The  deposit  may,  and  generally  does,  contain  a  mixture  of 
two  or  more  varieties  of  casts  and  cells. 

1  Arch.  f.  Exper.  PathoL,  vi.  p.  130. 

2  Yircli.  Archiv.,  vol.  79. 

3  Centralbl.  f.  Med.  AVissensch.,  1879,  p.  886. 
■*  Virch.  Arch.,  vol.  76. 

5  Journal  de  I'Anatomie,  1879,  p.  402,  and  Practitioner,  1882.  (On  the  subject 
of  Cast?,  see  Ziemssen's  Cyckipsdia,  v.  15,  p.  75,  and  Supplement  to  the  same, 
p.  639.) 


142  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

2.  Conclusions  as  to  their  pathological  meaning  must  be  de- 
duced from,  the  prevailing  tj'pes  rather  than  from  the  absence 
or  presence  of  one  or  iwo  of  a  particular  character.  For  exam- 
ple, it  must  not  be  assumed  that  the  kidneys  are  in  a  state  of 
hopeless  fatty  degeneration,  or  even  commencing  to  undergo 
that  change,  because  one  or  two  cells,  or  one  or  two  casts,  display 
oil  molecules. 

3.  It  is  necessary,  in  order  to  avoid  serious  errors,  to  examine 
specimens  of  urine  passed  on  two  or  three  separate  days. 

4.  Bearing  in  mind  these  precautions,  and  having  regard  to 
the  previous  history  of  the  case,  the  following  conclusions  are 
generally  warranted,  [a)  Epithelial  casts  and  blood-casts  indi- 
cate a  disease  of  recent  origin.  (6)  Transparent  large  waxy 
casts,  mixed  with  dark  granular  casts,  indicate  a  chronic  dis- 
ease, (c)  Epithelium  and  casts  containing  much  fat  indicate 
fatty  degeneration. 

Tube-casts  without  Appreciable  Albuminuria. — Tube-casts 
are  occasionally  found  in  urinary  deposits,  when  our  most  deli- 
cate tests  fail  to  detect  albumen  in  the  urine.  In  cases  of  passive 
renal  congestion  from  emphysema  or  regurgitant  heart  disease, 
small  hyaline  casts  specked  with  granules  are  often  found  with- 
out appreciable  albuminuria.  Similar  casts  are  also  found  in 
cases  of  icterus,  as  has  been  pointed  out  by  ISTothnagel  and  Fin- 
layson.^  In  acute  Bright's  disease,  the  discharge  of  tube-casts 
sometimes  continues  after  the  disappearance  of  the  albumen, 
and  in  cases  of  chronic  Bright's  disease,  when  the  albumen 
temporarily  disappears,  casts  are  still  sometimes  found  in  the 
deposit. 

In  most  of  these  cases  it  may  probably  be  assumed  that  albu- 
men is  really  present  in  the  urine,  but  in  so  small  a  quantity 
that  it  is  inappreciable  to  our  ordinary  tests.  It  has  been  too 
hastily  assumed  that  our  tests  for  albumen  are  infinitely  deli- 
cate, but  this  is  not  the  case.  In  urines  of  low  density,  where 
the  normal  ingredients  are  in  comparatively  small  proportion, 
nitric  acid  is  an  extremely  sensitive  test,  but  when  the  urine  is 
more  concentrated,  and  the  normal  ingredients  are  in  larger 
proportions,  a  not  inconsiderable  amount  of  albumen  may  be 
present,  and  yet  fail  to  give  any  reaction  with  nitric  acid.  A 
simple  experiment  is  sufficient  to  prove  this.  Take  an  ordinary- 
albuminous  urine,  and  dilute  it  with  water  until  it  gives  an  opa- 
lescence with  nitric  acid  only  after  the  lapse  of  forty-five  seconds 
after  the  addition  of  the  test.  Suppose  that  this  point  is  reached 
when  the  urine  is  diluted  with  200  times  its  bulk  of  water.  At 
this  point  the  diluted  urine  contains  0.0034  per  cent,  of  albumen. 

^  See  an  interesting  paper,  "  On  Tube-casts  without  Albuminuria,"  in  the  Brit, 
and  For.  Med.-Chir.  Eev.  for  January,  1876,  by  Dr.  Finlayson. 


FATTY    MATTER    IN    URINE.  143 

If  now,  instead  of  diluting;  with  water,  we  dilute  to  tPie  same 
point  Avith  a  healthy  non-albuniinous  urine,  neither  nitric  acid 
nor  heat  will  detect  the  leant  trace  of  albumen,  though,  of  course, 
it  must  contain  the  same  amount  as  when  it  was  diluted  with 
simple  water.  , 

III.— FATTY  MATTEE  IN  URINE. 

It  appears  highly  probable,  from  the  investigations  of  Dr. 
Schunck,  that  fatty  matter  is  contained  in  minute  quantities 
dissolved  in  normal  urine.  From  45  litres  of  healthy  urine  he 
obtained  0.14  gramme.  The  proceeding  he  adopted  was  to 
filter  successive  portions  of  urine  through  purified  animal  char- 
coal. The  charcoal  was  then  dried  and  treated  with  boiling 
alcohol.  By  repeated  evaporations  of  alcoholic  solutions  he 
obtained  a  quantity  of  a  white  solid  crystalline  fat  which  he 
considered  to  be  a  mixture  of  stearic  and  palmitic  acids.' 

Pathologically  fatty  matter  appears  in  urine  under  a  variety 
of  circumstances. 

1.  In  the  preceding  section  it  has  been  stated  that  tube-casts 
and  renal  epithelium  (sometimes  vaginal  epithelium  also)  are  liable 
to  undergo  fatty  degeneration,  and  oily  particles  then  appear 
in  the  urine,  either  enclosed  in  the  altered  cells  or  lying  free. 

2.  In  the  condition  called  chylous  urine,  free  fat  is  discharged 
in  great  quantity,  either  in  the  form  of  globules  visible  under 
the  microscope,  or,  more  commonly,  divided  into  molecules  so 
small  that  they  appear  onlj^  as  granular  particles,  under  the 
highest  magnifying  powers.     [See  Chylous  Urine.) 

3.  The  discharge  of  quantities  of  fluid  fat  by  the  kidneys  is 
a  phenomenon  so  extraordinary  and  unexpected,  that  its  occur- 
rence has  been  doubted.  There  is  no  doubt,  however,  that  cats 
and  dogs,  fed  with  an  excessive  quantity  of  fat,  excrete  oily 
matter  in  considerable  proportion  with  the  urine,  so  as  to  yield 
globules  visible  with  the  microscope.  There  appear  to  be  also 
a  few  well-authenticated  instances  of  the  occurrence  of  this  phe- 
nomenon in  the  human  subject.  The  late  Mr.  Turner  informed 
me  that  such  an  instance  fell  under  his  own  notice.  The  patient 
was  taking  cod-liver  oil,  and  each  day  there  was  a  discharge 
of  yellow  oil  with  the  urine.  Two  examples  have  also  been 
brought  forward  by  Dr.  C.  Mettenheimer ;  one  was  a  man  with 
cancer  of  the  lungs,  who  was  taking  dailj^  a  tablespoonful  of 
cod-liver  oil ;  the  second  was  a  woman  convalescent  from  acute 
nephritis,  who  was  taking  the  emulsio-cannabina.-     Dr.  Hen- 

1  "On  a  Crystalline  Fattv  Acid  from  Human  Urine,''  bv  E.  Schunck.     Proc 
Eoy.  Soc,  1867. 

T-  C.  Mettenheimer,  Archiv.  d.  Verein,  f.  Wissensch.  Arb.,  Bd.  i.  p.  374.  See, 
also,  A.  G.  Long's  Dorpat  Thesis,  "  De  adipe  in  urina  et  renibus,  etc."  (18o2). 
and  Rassmann,  Thesis,  "  Ueber  Eettharn,"  abstracted  in  Virch.  and  Hirsch 
Jahresb.,  1881. 


144  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

derson  likewise  describes  three  cases  of  heart  disease,  in  which 
oil  globules  appeared  on  two  or  three  occasions  in  the  urine 
("Brit.  Med.  Journ.,"  1858).  Mr.  Bowen  ("  Brit.  Med.  Journ.," 
1882)  relates  a  case  of  phthisis,  treated  by  cod-liver  oil,  in  which 
oil  globules  appeared  in  the  urine  and  vanished  after  the  admin- 
istration of  the  oil  was  stopped. 

Other  cases  are  reported,  by  Dr.  Oliver,  in  the  "  Brit.  Med. 
Journ."  of  1879. 

4.  Concretions  containing  fatty  matter  have  been  encountered 
in  the  urinary  bladder.     (See  Urostealith.) 

5.  Cholesterine, — Dr.  Beale  has  shown  that  the  oily  par- 
ticles so  frequently  seen  in  the  urinary  deposits  of  chronic 
Bright's  disease  contain  cholesterine  in  a  dissolved  state,  but 
spontaneous  deposits  of  cholesterine  crystals  appear  to  be  of 
extreme  rarity.  The  following  case  is  the  only  example  which 
has  fallen  under  my  observation : 

T.  M.,  set.  31,  a  pale  but  not  unhealthy  looking  mechanic,  called  on  me 
September  28,  1871.  He  stated  that  for  three  years  he  had  been  suffer- 
ing from  frequent  hsematuria  with  pain  and  aching  in  the  site  of  the  left 
kidney.  The  symptoms  corresponded  closely  with  those  of  a  case  of  left 
renal  calculus.  Careful  and  repeated  examination  of  the  loins  yielded 
no  physical  signs ;  the  patient  had  never  voided  any  stone  or  palpable 
gravel,  but  he  often  voided,  with  considerable  suffering,  cylindrical  worm- 
like bodies,  composed  of  fibrine,  which  I  judged  to  be  casts  of  the  ureter. 

At  my  request  he  voided  urine  into  a  clean  glass.  The  specimen  was 
very  bloody.  Under  the  microscope,  even  before  the  deposit  had  settled, 
I  discovered  numerous  plates  of  cholesterine.  These  were  mingled  with 
large  numbers  of  the  so-called  "granular  corpuscles,"  and  aggregations 
of  oily  particles  of  various  sizes  and  shapes,  together  with  free  fatty  mole- 
cules (see  Fig.  28).  Blood-corpuscles  were,  of  course,  abundant ;  and  these 
were  mixed  with  transitional  epithelial  cells — cylindrical  and  irregular 
— such  as  are  derived  from  the  pelvis  of  the  kidney ;  but  no  pus  globules. 
There  were  no  casts  of  tubes,  and  the  proportion  of  albumen  did  not 
exceed  that  which  might  be  accounted  for  by  the  blood.  The  general 
health  was  remarkably  good,  and  the  general  complexion  of  the  case 
bore  no  resemblance  to  any  type  of  Bright's  disease.  A  week  later  the 
patient  called  on  me  again,  and  brought  a  specimen  of  the  urine  which 
he  had  voided  on  the  morning  of  the  same  day.  It  had  a  similar  appear- 
ance to  the  one  just  described,  but  it  contained  much  less  blood.  It 
contained  large  quantities  of  granular  corpuscles  and  free  oily  molecules, 
but  only  a  few  cholesterine  crystals.  He  again  voided  urine  in  my  pres- 
ence, and  in  this  cholesterine  crystals  were  found  in  considerable  numbers. 
In  other  respects  it  resembled  the  preceding  specimens.  This  man  con- 
tinued under  my  observation  for  several  weeks,  and  the  urine  invariably 
exhibited  the  same  objects  under  the  microscope.  I  was  not  able  to 
satisfy  myself  as  to  the  cause  of  these  peculiar  appearances.  I  suspected 
the  existence  either  of  a  hydatid  cyst  opening  into  the  pelvis  of  the  kid- 
ney, or  commencing  general  cystic  degeneration  of  the  organ  ;   but  I 


FATTY    MATTER    IN    URINE. 


145 


could  not  discover  any  echinococci  booklets  in  the  urine,  nor  any  physical 
signs  of  renal  tumor. 

When  I  last  saw  this  man,  on  January  3, 1872,  very  marked  improve- 
ment had  taken  place  under  the  use  of  the  Liq.  ferr.  pernit.  The  blood 
in  the  urine  had,  for  six  weeks,  been  reduced  to  a  trace,  but  there  still 
existed  in  the  deposit  numerous  crystals  of  cholesterine,  and  abundance 
of  the  fatty  and  granular  particles. 

The  only  case  hitherto  recorded  at  all  comparable  with  the 
above,  so  far  as  I  know,  is  one  described  by  Dr.  Murchison. 
The  patient  was  a  man  of  fifty-four,  who,  for  fourteen  years, 
had  passed  large  quantities  of  pus  with  the  urine.     When  he 

Fig.  28. 


Cholesterine  crystals  and  fatty  aggregations  and  molecules  spontaneously  deposited  in  the  urine 
in  the  case  of  T.  M. 

came  under  observation,  three  days  before  his  death,  the  urine 
was  very  purulent,  and  contained  large  numbers  of  cholesterine 
crystals.  At  the  autopsy  the  right  ureter  was  found  blocked 
up,  but  not  entirely,  b}^  a  calculus.  The  kidney  was  wholly 
converted  into  a  large  (pyonephrotic)  cj^st,  containing  pus  rich 
in  cholesterine  crystals.  The  left  kidney  was  also  converted  in 
the  same  wa}^  but  not  so  completely,  into  a  suppurating  sac 
through  the  blocking  up  of  its  pelvis  with  a  large  branching 
stone.  The  pus  in  the  left  kidney  did  not  contain  cholesterine 
crystals.^ 

Reference  may  be  made  here  to  a  curious  case,  reported  by 

1  Path.  Soc.  Trans.,  xix.  278.  Pohl  (Virch.  and  Hirsch.  Jahresbericht,  vol.  i., 
1877)  found  cholesterine  in  the  urine  of  an  epileptic,  but  the  observation  was 
superficial. 

10 


146  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

Ebstein,^  of  pyonephrosis  with  a  tumor  in  the  ilank  in  which 
fat  globules  were  found  in  the  urine,  together  with  crystals  of 
hsemafoidin. 

6.  KiESTEiNE. — This  is  a  name  given  by  Nauche  to  a  peculiar 
pellicle  said  to  form  on  the  urine  of  pregnant  women  when  left 
at  rest  for  a  few"  days,  and  said  to  contain  fatty  and  caseous 
matter.  Much  has  been  written  on  the  nature  of  this  pellicle 
and  its  value  as  a  sign  of  pregnancy;  but  the  accounts  are  so 
contradictory  that  no  safe  conclusions  can  be  drawn  from  them. 
I  have  carefully  looked  over  all  the  observations  hitherto  made 
on  the  subject,  and  am  inclined  to  believe  that  the  kiesteine 
pellicle  is  nothing  more  nor  less  than  the  mould  fungus,  which 
is  apt  to  grow  luxuriantly  in  urines  containing  organic  matters. 
The  urines  of  pregnant  women  are  likely  to  form  a  fitting  nidus 
for  this  fungus  from  the  large  quantity  of  epithelial  debris 
which  they  generally  contain.  A  very  full  account  of  the  litera- 
ture of  this  subject  is  given  in  Montgomery's  "  Signs  and  Symp- 
toms of  Pregnancy."  A  paper,  by  R.  C.  Golding,  in  the  "British 
Obstetric  Record  "  for  1847-48,  and  another,  by  Hicks,  in  the 
"Lancet"  for  1859,  vol.  ii.  p.  281,  may  also  be  consulted.  The 
question  deserves  to  be  reexamined;  but  the  investigation,  to 
be  of  use,  must  be  conducted  with  much  more  rigorous  exactness 
than  any  hitherto  published. 

IV.— PUS  IN  UEINE. 

Urine  containing  pus  is  turbid  and  milky  when  voided. 
After  standing  a  while,  it  deposits  a  dense  yellowish-white 
sediment.  Pus  presents  a  very  different  appearance,  according 
as  the  reaction  of  the  urine  is  acid  or  alkaline.  In  the  former 
case  the  deposit  is  loose,  and  the  corpuscles  discrete ;  but  il 
the  urine  be  alkaline,  as  it  often  is,  from  ammoniacal  decompo- 
sition, the  pus  coheres  into  a  viscid  tenacious  mass,  which  can 
be  drawn  out  into  long  tough  strings.  The  latter  appearance 
is  diagnostic  of  pus. 

MiCRO-CHEMiCAL  CHARACTERS. — Pus  posscsses  an  analogous 
constitution  to  blood,  and  is  composed  of  cellular  particles  float- 
ing in  a  liquor  puris.  Liquor  puris,  like  liquor  sanguinis,  is  an 
albuminous  saline -fluid;  therefore  purulent  urine  necessarily 
contains  more  or  less  albumen — the  quantity  varying,  according 
to  the, proportion  of  pus  present,  from  a  trace  too  slight  for 
detection  by  ordinary  reagents,  to  a  considerable  impregnation. 
It  is  sometimes  a  point  of  importance,  and  alwaj^s  of  consider- 
able nicet}",  to  decide  whether  the  quantity  of  albumen  in  a 
purulent  urine  is  no  more  than  can  be  accounted  for  b}^  the  pus 

1  Deutsch.  Arch.  f.  klin.  Medic,  vol.  xxiii. . 


PUS  IN  urinj:.  147 

present,  or  whether  some  of  it  is  not  due  to  renal  disease.  Such 
a  question  occasionally  arises  in  cases  of  vesical  calculi  accom- 
panied with  catarrh  of  the  bladder — most  surgeons  holding  that 
the  coexistence  of  renal  degeneration  constitutes  a  bar  to  opera- 
tion. Usually,  purulent  urines  become  merely  hazy  witli  niti-ic 
acid;  and  the  quantity  of  pus  must  be  very  great,  indeed,  to 
account  for  a  large  deposit  of  albumen.  Important  assistance 
in  doubtful  cases  is  to  be  obtained  by  a  diligent  search  for  tube- 
casts  in  the  freshly  voided  urine. 

Fio.  29.' 


Pus  gloliules.     a.  Without  reageuts  ;   b.  After  the  addition  of  acetic  arid. 

The  chemical  test  for  pus  is  the  conversion  of  it  into  a  viscid 
mass  by  the  addition  of  Liq.  potassas  or  Liq.  ammoniae. 

The  pus  corpuscle  is  a  spherical  cell,  about  one-third  larger 
than  a  red  blood-disk.  Examined  without  reagents,  it  appears 
opaque,  granular  on  the  surface,  and  yellowish  (Fig.  29,  a).  The 
denser  the  urine  the  smaller  and  more  crumpled  becomes  the 
pus  corpuscle ;  whereas,  the  addition  of  water  expands  and  clears 
it — sometimes  bringing  into  view  the  nucleus.  This  effect  is 
brought  about  much  more  quickly  and  powerfully  by  a  drop  of 
acetic  acid,  insinuated  beneath  the  covering-glass.  The  nucleus 
thus  displayed  is  found  to  be  cleft  into  two,  three,  and  some- 
times four  nucleoli  (b).  If  the  acid  be  added  in  excess,  the  cell- 
wall  and  contents  disappear  altogether,  and  the  cleft  nuclei  float 
free  in  the  fluid. 

Clinical  Significance. — The  importance  of  pus  in  urine  de- 
pends on  its  source  and  quantity.  Suppuration!  may  take  place 
in  any  part  of  the  genito-urinary  passages,  or  abscesses  of  adja- 
cent parts  may  burst  into  these  and  cause  pus  to  appear  in  the 
urine.  It  is  therefore  always  desirable  to  decide  the  anatomical 
source  of  the  pus.  This  is  not  always  easy,  and  sometimes  it  is 
impossible.  The  following  are  the  points  to  be  held  in  view  in 
such  an  inquiry" : 

When  pus  is  derived  from  the  urethra  (as  in  gonorrhcea)  a 


148  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

drop  or  two  may  be  squeezed  from  the  meatus  urinarius  by 
compressing  the  penis.  Gonorrhoea  is  the  commonest  cause  of 
pus  in  the  urine  of  men.  The  quantity  is  always  small  and  the 
general  properties  of  the  urine  are  not  afiected  thereby. 

In  women  the  most  common  cause  of  slight  admixtures  of 
pus  with  the  urine  is  leucorrhoea,  which  betrays  itself  by  the 
coexistence  of  abundance  of  pavement  epithelium. 

Pus  from  the  bladder  has  a  more  serious  significance,  as  indi- 
cating the  existence  of  cystitis.  Usually  there  is  little  difficulty 
in  tracing  this  to  its  right  source  by  the  local  symptoms.  In 
severe  cases,  the  excessively  frequent  micturition,  the  ammo- 
niacal  state  of  the  urine  when  voided,  and  the  speedy  gelatiniza- 
tion  of  the  pus  into  a  viscid  mass,  leave  no  doubt  on  the  mind 
of  the  practitioner.  But  when  the  cystitis  is  slight,  and  of  old 
standing,  there  is  more  difficulty,  as  the  urine  may  retain  its 
acidity,  and  micturition  may  not  be  very  frequent.  The  presence 
of  stone  in  the  bladder,  an  enlarged  prostate,  the  history  of  a 
past  lithotomy,  or  of  an  old  stricture,  generally  gives  a  key  to 
the  source  of  the  pus. 

Suppuration  in  the  pelvis  of  the  kidney  (pyelitis)  is  generally 
indicated  by  direct  signs  of  irritation  in  the  loins.  When  these 
are  absent,  reliance  must  be  placed  on  finding  with  the  pus,  epi- 
thelial elements  of  transitional  character  {see  Fig.  23),  an  acid 
reaction  of  the  urine,  and  absence  of  signs  pointing  to  the 
bladder  and  urethra. 

The  bursting  of  an  abscess  into  the  urinary  passage  is  usually 
signalized  by  the  sudden  irruption  of  a  large  quantity  of  pus 
into  the  urine.  Perineal  abscesses  opening  into  the  urethra  can 
scarcely  be  overlooked ;  but  perivesical  and  perirenal  abscesses 
are  more  difficult  to  diagnosticate. 

Purulent  urine,  from  suppuration  in  the  kidney,  will  come 
under  consideration  in  future  pages.  [See  Suppuration  in  the 
Kidneys,  Pyonephrosis.) 

v.— BLOOD  IN  UKINE— HEMATURIA. 

An  admixture  of  blood  with  the  urine  is  readily  recognized  by 
the  color  which  it  Imparts  to  the  secretion,  unless  the  quantity 
be  very  small.  If  the  blood  is  derived  from  the  kidneys,  it  is 
diffused  equally  through  the  urine,  communicating  to  it  a  red- 
dish or  a  peculiar  smoky  tint,  and  after  standing  awhile  a 
chocolate-colored  grumous  deposit  subsides.  But  when  the 
blood  is  derived  from  some  part  of  the  urinary  tract  below  the 
kidneys — ureters,  bladder,  or  urethra — the  color  imparted  to  the 
urine  is  pinkish  or  vermilion,  and  frequently  distinct  clots  are 
found  in  the  deposit. 

The  microscope  is  the  surest  means  of  discovering  blood  in 


BLOOD    IN    URINE — HJiMATURIA. 


149 


urine;  nevertheless,  the  corpuscles  may  disappear  very  speedily 
if  the  urine  be  of  very  low  specific  ,i^ravity,  or  amnioniacal.  I?i 
acid  urine  of  moderate  density  (1020-25)  tlie  corpuscles  remain 
visible  and  preserve  their  form  for  several  days. 

They  do  not  run  into  rouleaux  in  the  urine,  as  they  do  when 
drawn  directly  from  the  bloodvessels,  but  stand  discrete  and 
separate.  In  dilute  urine  the  corpuscles  expand  somewhat  from 
imbibition,  and  appear  under  the  microscope  as  pale  circles  with 
sharp  delicate  outlines,  and  without  any  appearai)ce  of  cell-con- 
tents (see  Fig.  30,  a).     If  the  urine  be  more  concentrated,  they 

Fig.  30. 


Blood-corpuscles  in  iirine.     a.  Slightly  distended  by  imbibition  ;  6.  Showing  their 
biconcave  contour ;  c.  ShriTelled  :   d.  Serrated. 


preserve  more  nearly  their  normal  biconcave  contour,  and 
appear  smaller  and  more  deeply  shaded  (6).  Sometimes  they 
shrink  and  crumple  and  become  misshapen  in  various  ways  [cd). 
The  marks  by  which  blood-corpuscles  are  distinguished  from 
other  cells  found  in  urine  are,  the  extreme  tenuity  of  their  out- 
line, the  absence  of  visible  cell-contents,  and  especially  of  a 
nucleus,  and  their  feeble  refractive  power.  "When  the  bicon- 
cave form  is  preserved,  this,  of  course,  is  diagnostic.  Blood- 
disks  are  liable  to  be  confounded  with  confervoid  sporules,  with 
the  minute  discoid  forms  of  oxalate  of  lime,  and  with  the  nuclei 
of  renal  epithelium.  From  the  first,  they  are  distinguished  by 
the  absence  of  a  nucleus,  which  can,  with  a  good  glass,  always 
be  detected  in  the  sporules.  Sporules  also  generally  are  some- 
what oval,  often  elongated,  and  show  signs  of  budding.  The 
discoid  crystals  of  oxalate  of  lime  are  distinguished  by  the  exist- 
ence of  intermediate  forms  which  connect  them  with  dumb- 


150  ABNOKMAL    SUBSTANCES    IN    THE    URINE. 

bells.  Renal  nuclei  are  distinguished  by  their  strong  refraction, 
by  being  strongly  tinted  by  magenta/  and  usually  they  are 
surrounded>by  some  portion  of  the  material  which  originally 
invested  them.  The  coloring  matter  of  the  blood  in  urine  ma}^ 
also  be  detected  by  the  spectroscope  or  by  the  guaiacum  test. 
The  latter  is  conveniently  carried  out  in  the  following  manner : 
Pour  a  little  urine  into  a  narrow  test-tube  and  add  to  it  one  or 
two  drops  of  tincture  of  guaiacum  and  a  little  ozonic  ether. 
Shake  well  and  allow  to  stand  for  a  few  moments.  If  blood- 
coloring  matter  is  present,  the  ether  on  rising  to  the  top  of  the 
mixture  will  be  colored  blue.^ 

Urine  containing  blood  is  of  necessity  always  more  or  less 
albuminous.  The  quantity  may  be  so  great  that  the  urine  looks 
like  pure  blood,  ancl  coagulates  spontaneously,  or  so  small  that 
the  microscope  is  required  to  detect  it.  The  hemorrhage  may 
arise  from  a  great  variety  of  causes,  which  may  be  classified  as 
follows : 

1.  Local  lesions — external  injury,  violent  exercise,  calculous 
concretions,  ulcers,  abscesses,  cancer,  tubercle,  parasites,  active 
or  passive  congestion,  B right's  disease. 

2.  Symptomatic — in  purpura,  scurvy,  eruptive  and  continued 
fevers,  intermittent  fever,  cholera,  etc.,  mental  emotion. 

3.  SwpplemeMary  or  vicarious — to  menstruation,  hemorrhoids, 
asthma. 

Cases  also  occur  which  are  not  referrible  to  any  of  these  cate- 
gories, of  which  the  origin  is  extremely  obscure.^ 

1.  HEMATURIA  FROM  LocAL  Lesions. — This  division  includes 
by  far  the  largest  number  of  cases.  A  point  of  great  impor- 
tance is  to  ascertain  the  exact  source  of  the  blood.  This  is  not, 
as  a  rule,  difficult. 

Hemorrhage  from  the  substance  of  the  kidney  is  recognized  by 
the  existence  of  tube-casts  in  the  deposit.  By  far  the  most  com- 
mon cause  of  this  variety  of  hsematuria  is  some  form  of  Bright's 
disease  or  its  allies  (congestion,  etc.).  In  falls  and  blows  on  the 
loins,  or  any  injuries  supposed  to  implicate  the  kidneys,  the 
occurrence  of  casts  in  the  urine  furnishes  a  valuable  diagnostic 
sign.  In  the  following  remarkable  case  of  laceration  of  the 
kidney  from  a  fall,  the  condition  of  the  urine  was  accurately 
noted  from  the  time  of  the  accident  till  death. 

1  See  a  paper  by  the  author,  "  On  the  Effects  of  Magenta  and  Tannin  on  the 
Blood-corpufcles,"  in  the  Proceedings  of  the  Eoyal  Society  for  1863. 

2  If  the  patient  is  taking  iodide  of  potassium,  or  if  saliva  is  mixed  with  the 
urine,  the  test  is  inapplicable. 

Heller's  test  for  blood  in  the  urine  consists  in  boiling  the  urine  with  liq.  potassaj. 
The  precipitate  of  phosphates  which  is  then  thrown  down  is  colored  brown  if 
blood  be  present. 

^  It  may  be  necessary  to  remind  students  that  in  females  the  urine  is  generally 
bloody  during  the  menstrual  flow  ;  it  may  also  become  so  at  any  time  if  there  be 
uterine  and  vaginal  hemorrhage. 


BLOOD    IN    URINE  —  IITH  M  AT  U  R  J  A  .  151 

E.  Davis,  a  bricklayer,  aged  86,  was  brought  into  the  Manchester  In- 
firmary at  8  1'.  M.  ou  April  27, 1868,  in  a  state  of  complete  insensibility, 
with  gasping  respiration,  apparently  dying.  In  the  course  of  two  hours 
he  recovered  consciousness,  and  answered  questions  imperfectly,  in  a  half- 
drunken  manner.  It  appeared  that  he  went  to  his  work  in  the  afternoop 
intoxicated,  and  that  he  had  fallen  a  height  of  seven  stories.  Tiiere  was 
a  compound  fracture  of  the  skull,  and  the  legs  were  severely  contused 
and  lacerated.  From  the  time  that  he  recovered  speech  the  patient  con- 
tinued to  talk  in  a  curiously  incoherent  manner,  as  if  he  were  drunk — 
except  that  the  pronunciation  of  words  was  unaffected. 

No  urine  was  passed  on  the  day  of  the  accident ;  but  on  the  day  fol- 
lowing about  eight  ounces  were  withdrawn  by  catheter.  The  urine  was 
excessively  bloody,  dark  chocolate-colored,  and  highly  albuminous. 

On  the  third  day  (April  29)  the  patient  was  in  the  same  state.  No 
urine  was  passed  spontaneously ;  at  8  p.  M.  about  an  ounce  was  withdrawn 
by  catheter ;  it  was  of  the  same  character  as  before,  but  less  bloody,  and 
less  albuminous.  On  the  morning  of  the  fourth  day  I  found  the  patient 
breathing  rapidly,  with  a  quick  small  pulse;  the  tongue  was  moist ;  there 
was  great  thirst — no  appetite ;  the  bowels  had  been  opened  several  times 
by  medicine.  At  9  p.  m.  of  the  same  day  I  again  visited  the  ward.  No 
urine  had  been  voided,  and  the  bladder  was  not  distended.  The  general 
condition  was  evidently  worse ;  the  delirium  was  constant,  and  he  swore 
awfully  when  his  legs  were  touched. 

At  noon  on  the  fifth  day  the  patient  was  much  weaker  ;  the  breathing 
was  interrupted  ;  he  muttered  incoherencies  unceasingly;  and  waved  his 
hands  as  if  he  saw  spectres  in  the  air ;  he  picked  and  tore  the  bedclothes ; 
he  had  torn  three  sheets  to  ribbons,  and  had  torn  the  counterpane.  He 
did  this  quietly,  without  violence,  and  without  attempting  to  get  out  of 
bed.  When  asked  questions  he  answered  quite  at  random  ;  the  tongue 
was  dry  and  red ;  pulse  almost  imperceptible.  No  urine  had  been  passed 
spontaneously  this  day,  nor  the  day  before.  The  house  surgeon  introduced 
a  catheter,  and  succeeded,  by  compressing  the  abdomen,  in  withdrawing 
about  two  ounces  of  a  yellowish  urine,  with  small,  dark,  chocolate-colored 
granules  floating  in  it.  About  an  hour  after,  the  patient  died  quietly, 
without  coma  or  convulsions. 

During  the  five  days  that  the  patient  survived  no  urine  was  passed 
spontaneously ;  but  eleven  ounces  were  withdrawn  by  catheter  at  three 
different  times.  The  first  specimen,  drawn  the  day  after  the  accident, 
was  excessively  bloody ;  the  second,  drawn  on  the  third  day,  was  much 
less  bloody ;  the  third,  drawn  just  before  death,  contained  no  liquid  blood, 
and  had  a  yellow  color,  but  it  deposited  a  considerable  sediment  of 
chocolate-colored  granules  which  consisted  of  indurated  clots  of  blood. 
Although  this  last  specimen,  consisting  of  only  two  ounces,  was  the  pro- 
duct of  forty  hours'  secretion,  its  specific  gravity  was  only  1015,  and  its 
proportion  of  albumen  only  -^.  The  microscopic  examination  of  the 
deposits  revealed  the  existence  of  an  immense  quantity  of  casts  of  the 
uriniferous  tubes,  and  these  changed  character  as  time  passed  ovei'.  In 
the  first  specimen  the  casts  were  all  dark,  opaque,  and  granular  (Fig.  31, 
a,  c,  e),  evidently  composed  of  crushed  blood-clot;  no  free  renal  epithe- 
lium, nor  any  pyelitic  cells,  were  found.  In  the  second  specimen,  in 
addition  to  the  dark  granular  casts,  there  were  numerous  deep-brown 


152  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

plain  casts,  with  strongly  marked  outlines  and  very  few  markings  (d,  d)  ; 
a  few  transparent  casts  were  also  found,  some  of  them  studded  with  epi- 
thelium. In  the  second  and  third  specimens  free  renal  epithelium  (h,  i), 
and  epithelium  from  the  pelvis  and  infundibula  (g),  appeared  in  great 
abundance.  The  renal  epithelium  was  deeply  browned,  evidently  from 
hsematine,  but  was  otherwise  natural.  Many  of  the  casts  had  dumb- 
bells embedded  in  them. 


ace.  Dart  granular  casts  ;  6,  d.  Yellow  plain  cjists  ;  /.  Large  transparent  cast  studded  with  epithe- 
lium •  i  h.  Free  renal  epithelium,  i,  before,  and  h,  after  the  addition  of  acetic  acid ;  g.  Cells  from  the 
pelvis  and  infundibula. 

Autopsy  forty-eight  hours  after  death.  Left  parietal  bone  fractured, 
with  a  slight  depression.  Dura  mater  not  lacerated  ;  no  free  blood  on 
or  under  the  membrane ;  but  there  was  an  ecchymotic  patch  on  it  as 
large  as  a  florin,  corresponding  to  the  fracture.  There  was  no  blood  in 
the  arachnoid  space ;  but  the  pia  mater  was  injected  over  the  space  of 
two  square  inches  in  the  vicinity  of  the  fracture.  No  lymph  was  thrown 
out  on  any  part,  nor  was  there  softening  or  other  abnormal  condition  of 
any  portion  of  the  brain. 

Abdomen.  There  was  no  external  sign  of  direct  violence  over  the  loins  ; 
all  the  abdominal  organs,  except  the  kidneys,  were  uninjured  and  healthy. 
Left  kidney -weighed  9d  oz. ;  it  was  not  lacerated.  On  section  minute 
granules  of  indurated  blood  were  found  in  several  of  the  infundibula; 
the  whole  gland  was  hypersemic.  Right  kidney  weighed  di  oz.,  was  torn 
in  two  places  on  its  posterior  aspect.  The  lacerations  ran  across,  some- 
what crookedly,  from  the  outer  border  almost  to  the  hilum  ;  they  were 


BLOOD    IN    URINE  —  HJ<]MATURIA.  153 

about  an  inch  apart,  and  varied  in  depth  from  one  to  three  or  even 
four  lines.  They  were  completely  closed  by  a  wedge-shaped  solid  clot 
of  blood,  which  was  very  firm,  and,  where  in  contact  with  the  renal  sub- 
stance, bleached.  The  renal  tissue  immediately  adjacent  to  the  lacera- 
tions appeared  perfectly  natural — neither  injected  nor  softened.  The 
tunica  propria  was,  of  course,  torn  through  over  the  site  of  the  lacera- 
tions. The  lacerations  did  not  penetrate  in  any  part  to  the  infundibula, 
but  two  large,  firm,  blood-concretions — one  as  large  as  a  horse-bean,  and 
the  other  as  large  as  a  pea — lay  loose  in  the  pelvis,  and  several  smaller 
ones  were  found  in  the  infundibula.  The  perirenal  adipose  tissue  was 
deeply  stained  with  blood  on  both  sides;  but  it  contained  neither  fluid 
blood  nor  clots.  The  peritoneum  was  not  injured  nor  inflamed.  The 
heart  and  lungs  were  healthy. 

It  was  evident  that  the  direct  cause  of  death  in  this  case  was  suppres- 
sion of  urine — aided,  perhaps,  by  a  degree  of  delirium  tremens.  The 
reason,  probably,  why  no  signs  of  inflammation  were  found  in  the  brain 
and  peritoneum  was,  that  the  patient  never  really  rallied  from  the  shock 
of  the  accident ;  and  that  reaction  never  properly  took  place.  The 
desquamation  of  the  epithelium  of  the  pelvis  and  infundibula  must  be 
attributed  to  the  irritation  of  the  blood-concretions  found  therein. 

H?ematuria  is  rarely  serious  from  its  quantity  in  any  form  of 
Bright's  Disease,  and  is  generally  quite  insignificant.  Far  more 
serious  are  the  consequences  of  the  coagulation  of  the  effused 
blood  in  the  uriniferous  canals.  Unless  these  plugs  are  expelled 
by  the  pressure  of  the  urine  from  behind,  they  permanently 
block  up  the  tubes  and  destroy  the  function  of  the  correspond- 
ing portions  of  the  gland.  Hence,  any  hemorrhage  from  the 
substance  of  the  kidney,  however  it  may  arise,  is  attended  with 
serious  hazard  that  the  foundations  of  a  fatal  renal  degeneration 
may  be  laid  thereby. 

Cancer  of  the  kidney  is  often  associated  with  profuse  and 
repeated  hfematuria;  the  diagnosis  rests  chiefly  on  the  presence 
of  a  tumor  in  the  loins.     [See  Cancer  of  the  Kidney.) 

The  endemic  hsematuria  of  Mauritius,  Brazils,  Cape  of  Good 
Hope,  Egypt,  and  some  other  hot  countries,  which  so  greatly 
puzzled  pathologists  in  times  past,  seems  to  have  found  its  expla- 
nation in  the  presence  of  a  minute  parasite  wdiich  infests  the 
mucous  membrane  of  the  pelvis  of  the  kidney  and  the  bladder. 
The  researches  of  Griesinger,  Bilharz,  and  Dr.  John  Harley  on 
this  subject  will  be  described  in  the- chapter  devoted  to  parasites 
of  the  kidney.     {See  Bilharzia  H^matobia.) 

In  tubercle,  abscess,  renal  embolism,  hydatids,  tlie  liemor- 
rhage  is  seldom  more  than  trifling.  In  active  congestion  of 
the  kidneys  after  taking  turpentine  or  cantharides,  the  bleed- 
ing is  sometimes  severe.  As  these  classes  of  cases  are  treated 
separately  in  subsequent  parts  of  this  work,  it  will  not  be 
necessary  here  to  go  into  further  details. 


154  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

Sometimes  minute  calculous  concretions  are  formed  within 
the  tubuli  uriniferi,  and  occasion  hsematuria,  which  is  apt  to 
recur  again  and  again.  In |  these  cases  crystals  or  microscopic 
calculi  of  uric  acid,  or  oxalate  of  lime,  may  often  be  discovered 
bj  a  careful  examination  of  the  urinary  deposit  [see  Figs.  32  and 
33).     HEematuria  from  this   cause  may  be  unaccompanied  by 

Fig.  32. 


Blicroscopic  calculi  of  uric  acid,  with  fibrinous  casts  dotted  witli  crystalline  molecules  of  uric  acid 
in  a  case  of  recurrent  ha^maturia. 

any  pain  beyond  a  slight  aching  or  sense  of  fatigue  in  the  loins. 
Transparent  fibrinous  casts  are  also  visible  in  these  cases, 
speckled  all  over  with  crystalline  molecules,  and  more  albumen 
is  present  in  the  urine  than  corresponds  with  the  amount  of 
blood  voided. 

Hemorrhage  from  the  pelvis  of  the  kidney  and  ureters  is  com- 
monly due  to  calculous  concretions ;  much  more  rarely  to 
cancer,  tubercle,  cystic  disease,  or  parasites.  When  the  blood 
has  this  source  the  diagnosis  turns  on  the  existence  of  symp- 
toms of  pyelitis,  nephritic  colic,  and  the  passage  of  a  foreign 
body  down  the  ureter.  Sometimes  the  blood  coagulates  in  the 
ureter,  and  long  vermicular  clots  may  be  afterwards  recognized 
in  the  urine.  The  passage  of  these  clots  along  the  ureter  pro- 
duces precisely  the  same  symptoms  as  a  calculus  passing  in  the 
same  direction. 

Hemorrhage  from  the  bladder  is  usually  recognized  by  symp- 
toms pointing  directly  to  that  organ,  namely,  excessively  frequent 
micturition,  pain  in  the  hypogastrium,  and  at  the  neck  of  the 
bladder,  etc.  Exploration  of  the  bladder  will  generally  reveal 
the  existence  of  calculi  or  fungoid  growth.  Varicose  enlarge- 
ment of  the  veins  of  the  mucous  membrane  and  acute  cystitis 
are  also  occasional  causes  of  vesical  hemorrhage. 

Urethral  hemorrhage  is  known  by  the  escape  of  blood  in  the 
intervals  of  micturition. 

Symptomatic  HiEMATURiA. — Purpura  hemorrhagica  is  occa- 
sionally marked  by  severe  hrematuria.  In  a  case  under  my 
care  some  j-ears  ago,  there  occurred  first  violent  epistaxis  re- 


]'.LOOD    IN    UlUNE JlyKMATUKIA.  155 

quiring  plugging'  of  the  narea;  then  profuse  hiernaturia  set  in  ; 
when  this  subsided,  the  patient  rapidly  succumbed  to  intra- 
cranial hemorrhage.  Scurvy  is  more  rarely  attended  with 
hsematuria.  The  eruptive  and  continued  fevers,  cholera,  and 
yellow  fever,  are  sometimes  the  occasion  of  hsematuria,  which 
is  generally  a  very  unfavorable  symptom. 

Supplementary  IIti^matukia. — Many  curious  examples  have 
been  recorded  in  which  hasmaturia  appeared  to  be  swpplementarj.j 
to  some  natural  function  or  some  diseased  condition.  Chopart' 
relates  a  case  in  which  hsematuria  supplemented  a  hemorrhoidal 
flux;  Latour-^  adds  another.  The  latter  mentions  a  singular 
case  of  spasmodic  asthma,  of  such  severity  and  persistence  that 
the  patient  had  not  been  able  to  lie  in  bed  for  eighteen  months, 
which  disappeared  suddenly  on  the  occurrence  of  hsematuria. 
Chopart  and  P.  Frank  relate  examples  in  which  the  menstrual 
flux  was  deviated  to  the  urinary  passages,  and  appeared  under 
the  form  of  a  periodical  hsematuria.^ 

Mental  emotion  seems  capable  in  very  rare  instances  of  pro- 
ducing hfematuria.  BashamHells  of  a  shoemaker  who  was  subject 
to  attacks  of  hsematuria  which  always  recurred  on  the  occasion 
of  his  drunken  wife's  misconduct.  Rayer  records  an  instance 
in  which  hsematuria  followed  a  flt  of  passion. 

Treatment, — As  h?ematuria  is  merely  a  symptom,  and  a 
symptom  which  attends  a  great  variety  of  pathological  condi- 
tions, the  treatment  of  the  cases  in  which  it  occurs  is  necessarily 
diverse.  Sometimes,  however,  we  are  called  on  to  treat  haema- 
turia  for  itself — in  some  cases  because  of  our  inability  to  fathom 
its  exciting  cause,  in  others  because  the  loss  of  blood  is  so  great 
that  it  becomes  an  urgent  object  to  check  it,  even  though  the 
primary  disease  of  which  it  is  a  sj^mptora  be  irremovable. 

In  the  hyper{3emia  of  the  kidneys  which  occurs  in  acute 
Bright's  disease,  after  overdoses  of  turpentine  and  cantharides, 
after  blows,  falls,  muscular  efforts,  and  other  external  injuries, 
h?ematuria  is  a  positive  relief  to  the  loaded  vessels,  and  were  it 
not  that  the  effused  blood  is  prone  to  coagulate  in  the  uriniferous 
tubes,  and  produce  a  phj^sical  obstacle  to  the  excretion  of  urine 
of  a  most  dangerous  character,  the  hemorrhage  (unless  exces- 
sive) might  safely  be  left  to  its  own  course.  To  relieve  the  con- 
gestion in  these  cases,  derivation  by  the  loins  (cupping  etc.),  by 
the  cutaneous  surface  (baths,  diaphoretics),  and  by  the  intestines 
(hydragogue  cathartics),  must  be  energetically  practised. 

^  Traite  des  Malad.  des  voies  virinaires.     Segalas's  edition,  p.  283. 

2  Cited  by  Rayer,  t.  ii.  p.  25, 

*  Chopart  (1.  c.  p.  282)  cites  one  instance,  and  Eayer  two  instances,  in  -which 
hasmaturia  occurred  at  reguhir  monthly  periods  in  males.  One  of  these  was  a 
butcher  of  Sedan.  The  circumstance  became  known,  and  such  was  the  disgust 
caused  thereby  that  no  one  would  purchase  meat  from  him. 

•'Basham  on  Dropsy,  3d  ed  ,  p.  312. 


156  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

When  haematuria  is  supplementary  to  hemorrhoidal  dis- 
charges, leeches  may  be  applied  about  the  anus.  It  should  be 
remenibered,  however,  that  if  the  blood  be  shed  from  the  mucous 
membrane  of  the  bladder,  and  not  from  the  substance  of  the 
kidney,  such  a  discharge  is  not  to  be  looked  on  unfavorably,  nor 
to  be  rashly  suppressed.  When  moderate  hsematuria  occurs 
vicariously  with  menstruation,  it  is  to  be  suppressed  only  on 
condition  that  the  normal  flux  be  reestablished. 

Passive  hsematuria  in  the  course  of  zymotic  diseases  should  be 
carefully  distinguished  from  acute  B right's  disease,  which  some- 
times forms  a  sequela  to  these.  In  the  former,  the  bleeding  is 
probably  from  the  whole  or  greater  portion  of  the  urinary  tract, 
and  not  solely,  if  at  all,  from  the  kidneys.  The  internal  reme- 
dies]of  most  avail  in  passive  hesmaturia,  are  the  mineral  acids, 
especially  sulphuric  acid,  freely  administered. 

When  our  object  is  simply  to  treat  the  hsematuria  for  itself — 
to  stay  the  loss  of  blood — the  first  point  is  to  enforce  perfect 
rest,  and  to  apply  cold  in  the  most  effective  manner  to  the  bleed- 
ing part.  If  the  kidneys  be  the  source  of  the  blood,  ice-poultices 
should  be  applied  to  the  loins;  if  the  bladder,  iced-water  injec- 
tions may  be  practised  into  the  bladder,  and  iced-cloths  applied 
to  the  perineum  and  epigastrium.  The  medicinal  hsemostatics 
which  have  been  found  of  most  service,  are  gallic  acid,  acetate 
of  lead,  alum,  ergot  of  rye,^  tincture  of  muriate  of  iron,  turpen- 
tine, and  matico.  Dr.  Golding  Bird  speaks  highly  of  acetate  of 
lead  given  frequently  and  in  large  doses  for  short  periods.  He 
recommends  3  or  4  grains,  with  one-fourth  of  a  grain  of  opium, 
in  a  pill  every  two  hours,  until  six  or  eight  doses  have  been 
administered — care  being  taken  to  keep  the  bowels  open  by 
saline  purgatives.  Dr.  Prout  observes:  "When  the  bladder  be- 
comes distended  with  blood,  and  complete  retention  of  urine  in 
consequence  takes  place,  recourse  must  be  had  to  a  large-eyed 
catheter  and  an  exhausting  syringe,  by  the  aid  of  which,  and 
the  occasional  injection  of  cold  water,  the  coagula  may  be  broken 
up,  and  removed.  If  the  hemorrhage  be  so  profuse  that  the 
bladder  becomes  again  distended  with  blood  in  a  very  short  time, 
the  injection  of  cold  water  into  the  rectum  or  bladder  is  some- 
times of  great  use;  and  should  these  means  fail,  from  20  to  40 
grains  of  alum  may  be  dissolved  in  each  pint  of  water  injected 
into  the  bladder,  a  remedy  that  seldom  fails  to  check  the  bleed- 
ing even  when  the  cause  is  malignant  disease.  I  have  never 
known  any  unpleasant  consequences  follow  the  use  of  this  expe- 
dient; and  have  seen  it  immediately  arrest  the  most  formidable 
hemorrhage  when  all   other  means  had  failed,  and  when  the 

^  The  subcutaneous  injection  of  five  grains  of  ergotin  seems  worthy  of  trial, 
judging  by  the  successful  results  of  this  method  in  pulmonary  and  uterine  hemor- 
rhages.    See  Dr.  Ritchie,  Practitioner,  1871. 


HEMOGLOBINURIA.  157 

bladder  had  repeatedly  become  again  distentcd  with  blood  almost 
immediately  after  its  removal."^ 

VI.— HAEMOGLOBIN UlU A— PAROXYSMAL  HyKMOGLOBINURIA. 

HyBMATiNURiA. — Attention  hus  been  called  by  Vogcl,^  Oppolzer,^ 
and  Mettenheimer,''  to  the  escape  of  the  coloring  matter  of  the 
blood  (hseraoglobin)  with  the  urine,  unaccompanied  by  rupture 
of  the  capillaries  and  the  presence  of  blood-corpuscles.  The 
urine  in  such  cases  assumes  a  deep  red  or  blackish-red  color, 
very  much  as  if  it  contained  blood;  but  no  blood-disks  can  be 
found  under  the  microscope,  nor  any  fibrin.  This  condition  is 
invariably  accompanied  by  the  presence  of  albumen  in  the  urine. 
It  is  caused  by  the  rapid  destruction  of  the  blood-disks  in  the 
bloodvessels,  such  as  occurs  in  that  state  which  is  known  as  "a 
dissolved  state  of  the  blood,"  in  septic,  pyeemic,  and  putrid 
fevers,  and  in  some  extreme  cases  of  scurvy  and  purpura.  In 
such  cases  hsemoglobin  is  set  free  by  the  disintegration  of  the 
red  disks,  and  appears  in  the  urine.  Vogel  found  that  inhala- 
tion of  arseniuretted  hydrogen  produced  an  intense  (but  tempo- 
rary) degree  of  hsemoglobinuria.  He  produced  the  same  condi- 
tion artificially  in  animals  by  inhalation  of  the  same  gas  and  of 
carbonic  acid;  also  by  the  injection  of  substances  into  the  veins 
which  are  known  to  dissolve  and  break  up  the  red  disks. 

Ponfick  (Yirch.  "  Arch.,"  B.  72,  S.  273)  has  described  hemoglo- 
binuria as  occurring  after  the  transfusion  into  an  animal  of  blood 
from  an  animal  of  a  difierent  species.  He  believed  that  the 
heemoglobin  of  the  transfused  blood-corpuscles  was  dissolved  in 
the  serum  of  the  recipient  animal. 

Hsemoglobinuriahas  also  been  observed  after  severe  burns  Q), 
in  typhoid  fever  (^),  and  scarlet  fever  P),  after  fat  embolism  (*), 
and  in  poisoning  by  hydrochloric  acid  (^),  sulphuric  acid  Q, 
pyrogallic  acid  C),  carbolic  acid  (^),  and  chlorate  of  potash  (^).* 

A  case  of  ha-moglobinuria  from  chlorate  of  potash  poisoning, 
in  which  death  occurred,  was  described  by  Dr.  Dreschfeld  and 

iProut:  Stomach  and  Eenal  Diseases,  5th  edit.,  p.  421. 

^J.  Vogel:  Kranlvh.  der  Harnbereitenden  Organe.  in  Virchow's  Handbuch  der 
Speciellen  Path.  u.  Therap.,  Band  vi.,  2te  Abth.  p.  539. 
^"Wiener  med.  "Wochensch.,  1860,  Nos.  25  and  26. 

*  Wiirzburger  Med.  Zeitsch.  1862,  p.  1. 

*  (')  See  Lichtheim,  Volckmann's  Samml.  klin.  Vortrag.,  134.  (^)  Iiiimer- 
mann,  Deutsch.  Arch.  f.  klin.  Med.,  Bd.  12,  S.  502.  (3)  Heubner,  ibid.,  Bd.  23, 
S.  282.  (*)  Scriba,  Deutsch.  Zeitsclir.  f.  Chirurg.,  1879,  Bd.  12,  118;  Puedel,  ibid., 
Bd.  12,  S.  118,  1880.  (»)  Naunyn,  Dubois  Arch.,  1868,  S.  413  C)  Bamberger, 
Centralbl.  f.  Med.  Wissen.,  1874,  p.  571.  (■)Neisser,  Zeitschr.  f.  klin.  Medic,  Bd. 
1,  S.  88,  1880.  (8)  ZurNieden,  Berl.  klin.  Wochensch.,  1881,  p.  705.  [^)  Jacobi, 
New  York  Med.  Record,  1879,  xv..  No.  11  ;  Marchand,  Virch.  Arch.,  77,  p.  455. 
Catarrhal  jaundice  may  occasionally  be  accompanied  by  ha?moglobinuria.  This 
was  exemplified  by  a  case  I  saw  a  short  time  ago  in  consultation  with  my 
colleague  Dr.  Dreschfeld. 


158  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

Mr.  Stocks,  at  the  International  Medical  Congress,  London, 
1881.  The  patient,  a  woman,  had  taken  an  uncertain  quantity 
of  the  drug,  to  relieve  a  sore  throat.  Death  was  preceded  by 
great  cyanosis,  and  the  passage  of  quantities  of  haemoglobin 
from  the  rectum  and  vagina,  and  in  the  urine. 

The  clinical  significance  of  hsemoglobinuria  depends  entirely 
on  the  pathological  state  which  occasions  it. 


Paroxysmal  Hemoglobinuria. 

[Synonym — Intermittent  Hceniatinuria.) 

Attention  was  first  called  in  this  country  to  this  curious  dis- 
order by  Dr.  George  Harley,  who  published  two  cases  in  the 
^'  Med.-Chir.  Trans."  for  1865.^  Subsequently  cases  were  re- 
corded by  Dickinson,  Greenhow,  Gull,  and  others;  and  from 
an  analysis  of  these,  and  of  personal  observations,  together  with 
cases  reported  by  Continental  observers,  the  following  account 
has  been  drawn  up  :^  ^ 

The  disorder  is  essentially  intermitting  or  paroxysmal  in  its 
nature.  Each  paroxysm  begins  with  a  feeHng  of  cold  or  shiver- 
ing, resembling  the  cold  fit  of  ague,  and  terminates  with  the 
discharge  of  a  very  dark  bloody-looking  urine.  The  symptoms 
then  subside,  and  the  urine  at  the  next  micturition,  or  the  one 
after,  is  found  to  have  resumed  its  natural  healthy  appearance. 
The  recurrence  of  the  paroxysms  in  dift'erent  cases  is  most 
irregular.  In  some  cases  the  paroxysm  recurs  once  a  day,  or 
even  twice  and  thrice  a  day.  More  commonly  it  recurs  on 
alternate  days,  or  twice  a  week,  or  once  in  ten  days,  or  quite 
irregularly.  The  paroxysms  are  sometimes  followed  by  a  hot 
or  sweating  stage.  The  onset  of  a  paroxysm  is  usually  sudden. 
The  patient  first  experiences  coldness  of  the  extremities,  fol- 
lowed by  general  chilliness,  which  in  most  cases  passes  into 
distinct  rigors,  accompanied  by  a  feeling  of  malaise,  a  disposi- 
tion to  stretch  himself,  and  to  yawn.  In  most  cases,  a  sense  of 
weight,  or  a  dull  heavy  pain  is  felt  in  the  loins,  sometimes 
extending  to  the  umbilicus,  or  passing  down  the  thighs,  occa- 
sionally there  has  been  noted  tenderness  over  the  region  of  the 
kidnej^s ;  and  there  is  frequently  pain,  or  a  feeling  of  stiffness  or 
weakness,  in  the  lower  extremities.  Retraction  of  the  testicles 
has  been  noted  in  several  cases.     Retching  is  a  not  infrequent 

1  Dr.  Wickham  Le2:g,  in  his  admirable  paper  on  the  subject,  has  directed  atten- 
tion to  the  fact  that  Dessler,  in  1854,  published  a  complete  account  of  the  disorder 
in  Virchow's  Archiv  for  that  year. 

2  The  article  on  this  subject  in  the  preceding  edition  of  this  work  was  the 
result  of  an  analysis  of  twenty  cases.  Subsequently  more  numerous  observations, 
however,  have  rendered  necessary  many  alterations  and  additions. 


PAROXYHMA  li    IT yE M OGLOBI  N  U  K  I  A  . 


]o9 


symptom,  and  vomiting  was  a  prominent  feature  in  a  few  cases, 
wliilc  the  patient  sometimes  comjtlains  of  thirst,  headache,  and 
drowsiness. 

After  these  symptoms  have  lasted  for  a  period  varying  from 
thirty  minutes  to  two  hours,  the  patient  passes  a  (quantity  of 
dark-colored  urine;  the  pain  and  general  distui-haiu^e  tlien  suh- 
side,  leaving  the  patient  apparently  quite  well  till  the  next 
paroxysm. 

The  appearance  of  the  dark  urine  resemhles  that  of  porter  or 
of  the  darkest  port  wine.  It  is  generally  turbid,  and  deposits, 
on  standing,  an  abundant  chocolate-colored  sediment.  The 
sp.  gr.  varies  from  1015  to  1033,  usually  ranging  from  1022 
to  1025.  The  reaction  is  either  acid  or  faintly  alkaline.  It  is 
always  highly  albuminous,  and,  on  boiling,  the  albumen  coagu- 
lates into  brownish  masses,  which,  on  subsiding,  leave  the  clear 
supernatant  urine  of  nearly  its  original  dark-red  color.  In  Ilar- 
ley's  cases,  and  in  one  of  mine,  the  percentage  of  urea  was 
found  to  be  in  considerable  excess;  in  some  cases,  however,  it 
has  been  found  lower  than  usual. 

The  chocolate-colored  sediment  consists  chiefly  ot  amorphous 
granular  matter,  which  is,  presumably,  disintegrated  blood-cor- 

FiG.  33. 


Granular  matter,  casts,  and  octaliedra,  from  the  deposit  in  tlie  urine  uf  a  man 
with  paroxysmal  ha;moglobinuria. 

puscles.  Gull  found  in  it  myriads  of  minute  crystals  of  hsema- 
tine.  Casts  of  tubes  are  also  present ;  these  are  mostly  of  dark 
granular  appearance — mixed,  however,  with  a  few  transparent 
fibrinous  cylinders.  Many  casts  are  formed  of  masses  of  haemo- 
globin. Crystals  of  oxalate  of  lime  are  generally  seen,  and, 
very  rarely,  a  few  stray  blood-disks. 

The  urine  gives  the  usual  reactions  of  blood  with  the  guaiacum 
and  Heller's  tests.  Usually,  on  spectroscopic  examination,  there 
are  found  the  two  absorption  bauds  between  Frauenhofer's  D 


160  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

and  E  lines,  which  are  characteristic  of  oxhsemoglobin.  An 
additional  band  in  the  red,  indicating  the  presence  of  methsemo- 
globiri,  has  also  been  observed  by  many  writers.  Concerning 
this  band,  however,  there  is  some  difference  of  opinion,  and  no 
doubt  in  many  cases  it  is  absent. 

In  most  cases  the  albumen  and  the  haemoglobin  appear  and 
disappear  together.  Murri^  and  Rosenbach^  observed  albumen 
in  the  urine  before  the  blood-coloring  matter  could  be  per- 
ceived. This,  however,  has  not  been  confirmed  by  others.  Dr. 
Forrest,  on  the  other  hand,  found  that  the  albumen  persisted 
after  the  disappearance  of  the  hsemoglobin,  while  Dr.  Saundby, 
in  one  of  his  cases,  saw  the  blood-coloring  matter  in  the  urine 
when  no  trace  of  albumen  could  be  detected. 

During  the  attack,  the  extremities,  nose,  and  ears  may  be 
cold  and  cyanotic.  A  general  eruption  of  urticaria  has  been 
noticed  in  some  cases  by  Mackenzie,  Forrest,  Lichtheim,  and 
others.  In  a  few  cases  the  liver  and  spleen  increased  in  size 
during  the  attack;  and  in  Boas's  case,  pains  in  the  region  of  the 
liver  seemed  to  be  precursors  of  an  attack. 

Careful  examination  of  the  blood  during  the  attacks  has  been 
made  by  recent  observers,  particularly  hy  Ehrlich,  Boas,  and 
"Wolff.  The  main  changes  observed  were,  absence  of  the  ordi- 
nary rouleaux  of  red  blood-corpuscles,  variations  in  shape  of  the 
red  corpuscles,  and  the  presence  of  Ponfick's  so-called  "  phan- 
tom" corpuscles,  or  red  corpuscles  from  which  the  coloring 
matter  had  been  dissolved  out.  Sometimes,  however,  the  hiicro- 
scopical  examinations  of  the  blood  have  shown  no  change.  The 
temperature  daring  the  paroxysm  is  usually  raised,  in  one  of 
Dr.  Saundby's  cases  to  as  high  as  105.2°  It  may,  however,  be 
normal,  or  in  some  cases  a  preliminary  fall  may  precede  the  rise. 
{See  Charteris,  "  Lancet,"  Jan.  1879.) 

The  first  onset  of  the  disorder  is  invariably  sudden,  and  can 
usually  be  traced  to  some  distinct  exposure  to  cold  or  wet.  The 
subsequent  paroxysms  are  generally  quite  unconnected  with 
any  fresh  exposure  to  cold,  but  in  other  cases  the  contrary  is 
the  case.  The  paroxysms  recur,  in  some  cases,  with  the  regu- 
larity of  real  ague,  for  weeks  together ;  in  other  cases  the  perio- 
dicity is  quite  imperfect.  Each  paroxysm  lasts  from  three  to 
twelve  hours,  and  it  is  noteworthy  that  no  paroxysms  occur  at 
night,  the  urine  voided  before  breakfast  being  invariably  natu- 
ral.^ The  change  in  the  characters  of  the  urine  may  take  place 
with  the  utmost  abruptness;  that  passed  at  one  micturition 
being  porter-like,  and  at  the  next  straw-colored;  or  it  may  more 

1  Kevista  clinica  di  Bologna,  1879.  ^  Berlin,  klin.  Wochen.,  1880,  p.  132. 

*  See,  however,  a  case  reported  by  Lepine  (Revue  Mensiielle,  1880,  p.  722),  in 
which  cold  had  no  influence,  and  the  paroxysms  occurred  at  midnight. 


PAROXYSMAL    II  iE  MOGLO  J{  I  N  U  R  I  A  .  ItJl 

gradually  bocoiue  pale,  resuming  its  normal  a[)[)oarance  at  the 
fourth  or  fifth  micturition  after  the  paroxysm. 

The  state  of  the  general  health  seems  to  vary  somewhat.  In 
one  case  reported  by  Dr.  Dickinson,  the  patient  had  the  appear- 
ance of  robust  health  the  day  l)efore  an  attack  came  on.  In 
most  cases,  however,  the  patient  has  pi-esented  a  somewhat  sal- 
low and  icteric  aspect,  or  has  looked  ansemic,  pale,  and  sickly. 
Sometimes  there  has  been  hepatic  derangement  distinctly  present 
at  the  time  the  patient  has  come  under  observation.  In  one 
case,  an  intercurrent  attack  of  jaundice  came  on,  the  urine  being 
deeply  colored  with  bile,  and  copiously  depositing  lithates,  but 
containing  no  blood-coloring  matter,  and  only  once  a  trace  of 
albumen.  Occasionall}^,  after  severe  paroxysms, the  conjunctivae 
are  of  a  yellowish  color,  but  no  bile  pigment  is  found  in  the 
urine.  The  color  is  probably  due  to  serum  holding  haemo- 
globin in  solution,  which  is  transuded  during  the  attack. 

A  rheumatic  tendency  is  a  frequent  concomitant  of  this 
affection,  many  of  the  patients  having  frequently  sufi!ered  from 
rheumatism  in  various  forms.  In  one  of  my  own  cases  the 
patient  began  to  suffer  from  subacute  rheumatism,  with  swell- 
ing and  pain  in  the  joints  after  the  cessation  of  the  paroxysms. 
A  bronchitic  and  asthmatic  tendency  has  also  been  observed  in 
one  or  two  instances.  FraentzeP  is  of  opinion  that  there  is  a 
decided  tendency  to  chronic  lung  disease. 

Of  twenty  cases  collated  by  me,  four  had  at  one  time  or 
another  suffered  from  undoubted  ague,  but  in  the  remainder 
no  evidence  or  suspicion  of  ague  or  malarial  poison  existed. 

The  course  of  the  disorder  is  an  interrupted  one.  The  parox- 
ysms may  recur  with  more  or  less  regularity  for  a  period  of  a 
few  days,  or  ffve  or  six  weeks,  and  then  cease  altogether  for  a 
few  days  or  weeks,  or  months,  and  recur  again  for  a  period  as 
before.  In  this  way  it  may  continue  an  interrupted  course  for 
many  months  or  years ;  in  one  case  for  so  long  a  term  as  eleven 
3'ears. 

The  prognosis  is  generally  good.  Of  the  twenty  cases  men- 
tioned above  none  died,  twelve  were  reported  as  having  com- 
pletely recovered,  one  was  convalescent,  and  seven  were  still  in 
progress  when  reported.  By  complete  recovery  is  understood 
that  there  was  no  recurrence  of  the  paroxysms  for  a  period 
varying  from  six  weeks  to  four  years.  It  must,  however*  be 
borne  in  mind,  that  a  relapse  may  take  place  after  a  pause  of 
several  months — in  one  case  a  recurrence  took  place  after  a 
pause  of  live  months. 

The  following  three  examples  will  serve  to  illustrate  the  gen- 
eral course  and  symptoms  of  the  disease.     The  first  and  second 

1  Berl.  klinisch.  Wochenschr.,  1881,  p    42. 
11 


162  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

were  observed  by  myself,  the  third  by  Dr.  Ritchie ;  these  cases 
have  not  been  elsewhere  published  : 

Case  1. — J.  J.,  an  iron  moulder  from  Stockport,  set;  23,  consulted  me 
in  March,  1868.  He  was  thin  and  weak,  with  a  conspicuously  white, 
pallid  countenance.  He  stated  that  for  a  period  of  twelve  months  he 
had  been  in  the  habit  of  passing  dark  bloody-looking  urine  from  time  to 
time  at  frequent  intervals.  His  complaint  began  in  the  following 
manner :  He  was  standing  in  the  street  one  cold  afternoon  in  March  of 
the  previous  year,  when  he  was  seized  with  chilliness  and  shivering  and 
pain  in  the  loins.  When  he  got  home  he  voided  urine,  and  was  surprised 
to  see  it  of  a  dark- red  color.  From  this  time  up  to  the  date  of  his  visit 
to  me  he  continued,  with  only  short  intervals,  to  pass  every  day  urine 
of  a  similar  character.  He  became  so  weak  that  he  did  not  leave  his 
house  for  ten  months;  but  he  never  took  to  his  bed,  except  for  a  day 
or  two. 

The  discharge  of  the  dark  urine  was  essentially  paroxysmal  and  inter- 
mittent. He  would  go  on  passing  bloody  urine  daily  for  periods  vary- 
ing from  three  to  six  weeks — then  the  urine  would  be  natural  for  an 
interval  of  three,  four,  or  even  ten  days,  and  then  become  bloody  again 
for  a  stretch  of  several  weeks.  But  the  urine  was  never  constantly 
bloody  during  any  whole  period  of  twenty-four  hours.  During  each 
diurnal  circle,  three  paroxysms  occurred  with  great  regularity :  one  in 
the  morning  (after  breakfast)  between  nine  and  ten,  a  second  between 
two  and  three  in  the  afternoon,  and  a  third  between  six  and  nine  in  the 
evening.  Each  paroxysm  presented  the  same  succession  of  symptoms. 
It  began  with  chilliness,  which  speedily  went  on  to  shivering  so  that  his 
teeth  chattered — at  the  same  time  there  was  severe  pain  in  the  loins  and 
hips.  At  the  end  of  twenty  or  thirty  minutes  these  symptoms  wore  off, 
and  then  he  felt  a  desire  to  void  urine — and  the  urine  then  passed  was 
always  bloody  ;  this  completed  the  paroxysm.  It  was  never  followed  by 
a  hot  or  sweating  stage.  If  he  made  water  between  the  paroxysms,  the 
urine  was  either  perfectly  clear  and  natural,  or  only  slightly  dark.  The 
urine  voided  before  breakfast  was  always  quite  natural. 

The  patient  visited  me  several  times,  and  brought  me  several  speci- 
mens of  the  bloody  urine.  On  one  occasion  he  voided  some  in  my  pres- 
ence, and  a  description  of  this  will  answer  substantially  for  all  the  rest. 
It  was  of  the  color  of  the  darkest  port  wine — so  dark  as  to  be  almost 
opaque,  except  in  thin  layers ;  it  corresponded  pretty  closely  to  No.  9 
on  Vogel's  scale.  A  brownish  deposit  formed  on  standing ;  sp.  gr.  1028  ; 
it  was  highly  albuminous,  and  faintly  alkaline.  On  boiling,  the  albu- 
men coagulated  into  a  chocolate- colored  clot,  but  the  supernatant  fluid 
did  not  lose  its  black-red  color.  The  deposit  consisted  of  a  granular 
matter.  It  contained  numerous  crystals  of  oxalate  of  lime ;  but  no 
blood-disks  could  be  recognized. 

In  April  I  admitted  the  patient  into  the  Infirmary,  with  a  view  of 
studying  his  case  more  fully.  But,  with  the  exception  of  the  first  morn- 
ing, the  urine  was  perfectly  normal  throughout  his  stay,  and  he  went 
home  in  a  week.  While  in  the  Infirmary  his  blood  was  examined  under 
the  microscope,  but  nothing  unusual  was  found.  The  liver  and  spleen 
were  thought  to  be  somewhat  larger  than  usual — otherwise  all  the  organs 


PAROXYSMAL    II^<]  M  OG  LO  JM  N  U  HI  A  .  163 

were  healthy.  After  leaving  the  Infirmary,  he  continued  to  attend  as 
an  out-patient  for  some  months — taking  constantly,  three  times  a  day,  a 
pill  containing  three  grains  of  (juinine  and  one  grain  of  sulphate  of  iron. 
Under  this  treatment,  the  symptoms  gradually  suhsided,  the  paroxysms 
became  slighter  and  slighter,  and  at  the  end  of  three  months  ceased  alto- 
gether. The  general  health  also  greatly  improved.  After  the  cessation 
of  the  paroxysms,  he  began  to  suffer  from  subacute  rheumatism,  with 
swelling  and  pain  in  the  joints.  He  was  troubled  in  this  way  for  more 
than  a  twelvemonth,  and  went  to  Buxton,  where  he  derived  great  benefit, 
and  finally  recovered.  I  saw  this  man  a  few  days  ago  (March,  l-STO)  ; 
there  had  been  no  return  of  the  paroxysms,  and  he  looked  well  and 
ruddy. 

The  patient  stated  positively  that,  except  at  the  first  onset  of  his  com- 
plaint, the  paroxysms  came  on  independently  of  exposure  to  cold ;  he 
was  just  as  bad  in  the  summer  as  in  the  winter.  Throughout  his  illness 
he  ate  and  slept  well.  He  had  never  lived  in  an  aguish  district,  and  he 
still  occupies  the  same  house  as  when  his  ailment  commenced. 

Case  2. — The  notes  of  this  case  are  imperfect,  and  my  own  observa- 
tions are  confined  to  an  examination  of  the  urine.  On  November  28, 
1871,  my  colleague.  Dr.  Renaud,  sent  me  two  samples  of  urine  which 
had  been  voided  by  the  same  man  at  different  periods  of  the  same  day. 
The  contrast  between  the  two  samples  was  marvellous.  One  sample  was 
of  the  usual  yellowish-amber  color,  clear  and  free  from  a  trace  of  albu- 
men— in  short,  perfectly  normal.  The  other  was  of  the  blackest  red 
color,  quite  opaque,  except  in  the  thinnest  layers.  Its  sp.  gr.  was  1032 ; 
it  was  so  albuminous  that  it  solidified  into  a  chocolate-colored  jelly  when 
boiled  in  a  water-bath.  On  standing,  it  deposited  a  copious  dark-brown 
sediment.  Under  the  microscope  (see  Fig.  33)  this  was  found  to  consist 
of  amorphous  granular  matter,  amid  which  were  seen  numbers  of  tube- 
casts.  The  casts  were  mostly  of  a  medium  size,  and  dark  granular  char- 
acter. Some  were  small,  and  a  few  almost  transparent  and  approaching 
the  hyaline  character.  Not  a  single  recognizable  red  blood-disk  could 
be  seen,  but  a  few  corpuscles,  resembling  the  white  blood-globules,  were 
scattered  here  and  there.  The  field  was  full  of  minute  bright  specks  of 
oxalate  of  lime  octahedra.  The  proportion  of  urea,  as  ascertained  by 
Liebig's  method,  was  5.2  per  cent. 

When  the  urine  was  boiled  in  a  test-tube,  the  brown  albuminous  clots 
separated,  and  left  a  dark  amber*  transparent  supernatant  liquor. 

The  history  of  the  case,  as  far  as  it  was  gathered  by  Dr.  Renaud,  was 
as  follows :  The  patient  was  a  man  of  forty,  of  a  sallow  complexion,  who 
felt,  nine  weeks  before,  as  if  he  had  taken  cold.  A  fortnight  since  he 
lost  his  appetite,  and  shivered,  and  afterwards  perspired.  He  kept  his 
bed  four  days.  On  November  21st  he  passed,  at  noon,  urine  the  color 
of  blood ;  and  he  has  done  so  nearly  at  the  same  time  (i.  e.,  once  in 
twenty-four  hours)  till  yesterday.  At  other  times  of  the  day  he  passed 
urine  of  the  natural  color.  I  have  not  been  able  to  obtain  further  par- 
ticulars of  this  case. 

Case  3.  (From  the  notes  of  Dr.  Ritchie.) — T.  M.,  a  tailor,  married, 
set.  32,  consulted  me  on  December  18,  1869.  He  was  above  the  medium 
height,  dark-complexioned,  and  had  a  sallow  appearance.  He  gave  the 
following  account  of  himself:    He  had  formerly  been  a  soldier,  and  had 


164  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

lived  for  nine  years  in  the  West  Indies ;  during  that  time  he  had  suffered 
from  "  black  fever,"  and  from  repeated  attacks  of  ague,  the  last  of  which 
seized  him  towards  the  end  of  1865.  These  were  the  only  illnesses  he 
could  remember  till  March,  1869,  when  he  reminded  me  he  had  been 
under  my  care  in  the  out-patients'  room  of  the  Manchester  Royal  Infir- 
mary, suffering  from  pleurisy  with  limited  effusion  ;  and  again,  in  Sep- 
tember, 1869,  from  subacute  rheumatism. 

He  now  complained  of  passing  bloody-looking  urine  once  or  twice  a 
day — that  passed  in  the  intervals  being  apparently  quite  healthy.  He 
first  observed  this  symptom  about  two  years  before,  under  the  following 
circumstances :  He  had  been  engaged  in  some  gymnastic  exercise  one 
November  evening,  and  feeling  greatly  overheated,  had  imprudently 
gone  to  the  door  of  the  gymnasium  to  cool  himself,  when  he  was  sud- 
denly seized  with  chilliness  and  violent  shivering,  followed  by  severe 
pain  across  the  loins,  and  a  feeling  of  nausea.  About  an  hour  afterwards 
he  voided  a  small  quantity  of  urine  having  the  color  of  porter.  The 
urine  passed  the  next  morning  before  breakfast  was  apparently  quite 
natural,  but  at  night  the  porter-like  color  was  again  present.  For  about 
two  months  the  discharge  of  this  dark  urine  took  place  once  or  twice 
every  day,  and  then  spontaneously  ceased.  He  had  had  two  similar 
attacks  since — one  in  March,  1868,  lasting  about  six  weeks,  and  the 
other  in  September  of  the  same  year,  lasting  nearly  four  months. 

His  present  attack,  which  was  the  most  severe  he  had  yet  suffered 
from,  began  about  a  fortnight  before  he  came  to  see  me.  It  immedi- 
ately followed  exposure  to  cold  and  wet,  and  was  ushered  in  by  all  the 
premonitory  symptoms  which  characterized  his  previous  seizures.  The 
phenomena  observe  the  following  order :  He  feels  perfectly  well  on  get- 
ting out  of  bed  in  the  morning,  and  usually  passes  about  ten  or  twelve 
ounces  of  straw-colored  urine;  about  ten  o'clock  he  begins  to  yawn  and 
shiver,  and  feels  "  as  if  he  couldn't  stretch  himself  enough ;"  he  then 
suffers  a  dull,  heavy  pain  across  the  loins,  which  sometimes  extends 
round  to  the  umbilicus,  passing  down  the  thighs ;  the  testicles  become 
retracted.  There  is  no  pain  along  the  course  of  the  ureters.  The  shiver- 
ing and  lumbar  pain  increase  for  about  an  hour,  at  the  end  of  which  he 
usually  passes  from  eight  to  ten  ounces  of  porter-like  urine,  upon  which 
the  symptoms  gradually  disappear.  He  usually  voids  urine  again  about 
one  or  two  o'clock,  which  to  all  appearance  is  perfectly  healthy.  About 
four,  the  same  succession  of  phenomena  runs  its  course,  to  be  followed 
by  the  discharge  of  dark  urine  about  five,  and  again  about  ten  o'clock 
in  the  evening.  He  has  thus  had  three  distinct  paroxysms  every  day 
from  the  2d  to  the  15th  of  December — remaining  perfectly  free  from 
them  between  the  night  of  the  15th  and  eleven  o'clock  in  the  forenoon 
of  the  18th,  when  he  began  again  to  pass  the  porter-like  urine.  He 
stated  that  he  usually  went  to  bed  when  he  felt  the  paroxysm  coming 
on,  and  that  he  had  the  greatest  difficulty  in  keeping  himself  warm  ; 
"  so  different,"  as  he  remarked,  "  from  what  it  used  to  be,  when  he  would 
have  the  ague." 

It  was  about  2  p.m.  on  the  18th  when  he  came  to  see  me,  and  he  was 
requested  to  send  for  me  on  the  occurrence  of  the  next  paroxysm.  A 
message  was  received  from  him  about  9.15  the  same  night,  and  half  an 
hour  afterwards  I  was  with  him.     He  was  in  bed,  shivering  violently, 


PAROXYSMAL    HyK  MOGLOBl  W  URI  A  .  165 

and  feeling  very  cold  ;.his  temperature  in  the  axilla  was  i)().(P  Fahr.  ; 
he  suffered  from  the  lumbar  pain  and  feeling  of  sickness  previously 
described  ;  the  testicles  were  closely  retracted.  lie  was  ordered  a  warm 
drink,  and  to  have  an  additional  pair  of  blankets  on  his  bed. 

A  few  minutes  after  my  arrival,  he  passed  a  quantity  of  urine,  which 
was  secured  for  the  purpose  of  examination.  Five  minutes  afterwards, 
he  said  that  he  was  perfectly  free  from  pain  and  discomfort,  and  felt 
quite  well.  His  temperature  was  then  98.6°.  There  was  slight  ten- 
derness over  both  kidneys  on  deep  pressure,  and  also  over  the  eleventh 
and  twelfth  dorsal  vertebrte.  Lungs  apparently  healthy,  with  the  excep- 
tion of  slight  comparative  dulness  over  the  right  back — no  doubt  the 
remnant  of  the  pleurisy  from  which  he  had  suffered  in  the  preceding 
March.  Heart  sounds  and  rhythm  normal.  Liver  measured  five  inches 
vertically  in  the  maramillary  line.  Spleen  nearly  three  and  a  half 
inches;  colorless  blood-corpuscles  slightly,  but  not  markedly,  increased. 
His  general  health  was  good ;  appetite  fair ;  bowels  had  not  been 
relieved  for  two  days. 

The  urine  which  he  was  seen  to  pass  measured  eight  ounces;  it  was 
not  unlike  porter  in  color,  but  had  a  redder  tint ;  it  was  almost  opaque 
— neutral  or  feebly  alkaline  in  reaction ;  sp.  gr.  1026.  It  contained  a 
large  amount  of  albumen  which,  on  the  application  of  heat,  was  thrown 
down  in  the  form  of  a  chocolate-colored  clot,  increased  on  the  addition 
of  nitric  acid  ;  the  coagulum  occupied  about  half  the  bulk  of  the  urine 
examined,  the  supernatant  fluid  retaining  its  intensely  dark  reddish- 
brown  color.  On  microscopic  examination,  it  was  found  to  contain 
abundant  octahedral  crystals  of  oxalate  of  lime,  a  few  granular  tube- 
easts,  a  large  quantity  of  granular  matter  of  a  dark  brownish-red  color, 
and  a  quantity  of  amorphous  urates.  No  blood-corpuscles  could  be 
detected. 

The  urine  passed  on  the  morning  of  the  19th  December,  before  break- 
fast, possessed  the  following  characters :  it  measured  about  10^  ounces, 
was  of  a  light  amber  color,  acid,  sp.  gr.  1018  ;  contained  no  albumen ; 
on  standing,  the  dense,  snow-white,  cloud-like  deposit,  characteristic  of 
the  presence  of  oxalates,  was  thrown  down.  Under  the  microscope,  it 
was  seen  to  contain  octahedral  crystals,  pavement  epithelium,  and 
granular-looking  cells. 

The  usual  course  of  the  paroxysms  was  observed,  viz.,  that  porter-like 
urine  was  voided  three  times  a  day,  preceded  by  the  same  succession  of 
symptoms.  He  was  first  ordered  ten-grain  doses  of  gallic  acid  three 
times  a  day,  then  tannic  acid,  and  afterwards  turpentine,  without  the 
slightest  change  in  his  symptoms.  On  the  28th  December,  he  was  ordered 
two  pills  three  times  a  day,  each  containing  sulphate  of  quinine  3 
grains,  sulphate  of  iron  1  grain,  and  strychnia  gig-  grain.  Under  tljis 
treatment  he  gradually  improved,  the  paroxysms  coming  on  less  fre- 
quently, and  being  milder  in  their  character,  till  the  17th  January,  1870. 
He  remained  perfectly  free  from  that  date  till  the  5th  of  April,  w'hen  he 
had  another  similar  attack  after  a  sudden  chill.  The  paroxysms  on 
this  occasion  were  slighter,  and  only  came  on  twice  daily,  viz.,  in  the 
forenoon  and  at  night.  The  ui-ine  presented  the  essential  characteristics 
described  fully  above.    He  was  placed  on  the  same  treatment  which  had 


166  ABNORMAL    SUBSTANCES    IN    THE    URINE, 

proved  successful   on  the  former  occasion,  and  the  paroxysms  ceased 
entirely  on  the  14th  of  April. 

I  had  lost  sight  of  this  patient  till  the  31st  March,  1871,  when  a  letter 
was  received  from  him,  stating  that  he  had  gone  to  reside  in  the  north 
of  Ireland,  and  that  he  had  remained  perfectly  free  from  his  former 
attacks  from  the  time  I  had  seen  hira  last  till  the  beginning  of  that 
month.  He  had  then  suffered  for  nearly  a  fortnight  a  recurrence  of  his 
former  complaint,  from  which  he  had  just  recovered  under  the  use  of 
the  same  treatment  that  had  been  previously  adopted. 

Etiology. — The  liability  to  paroxysmal  hsemoglobinuria  seems 
to  be  almost  exclusively  confined  to  males,  one  only  of  twenty 
collated  cases  occurring  in  a  female.  The  age  of  the  patients 
at  the  time  of  invasion  ranged  from  2  years  of  age  to  48 ;  two 
cases  being  under  20,  seven  between  20  and  30,  six  between  30 
and  40,  two  between  40  and  50,  and  three  cases  in  which  the 
date  of  invasion  is  not  specified.  A  hereditary  tendency  has 
been  occasionally  noticed. 

Hsemoglobinuria  has  been  known  to  occur  occasionally  in  the 
course  of  chronic  Bright's  disease. 

As  to  the  exciting  cause  of  the  disease,  in  two  cases  out  of  the 
above  twenty  it  was  found  distinctly  connected  with  malarial 
poisoning,  both  patients  actually  sufiering  from  ague  at  the  time 
the  hsemoglobinuria  was  first  "observed.  In  all  the  other  cases 
(with  one  exception)  the  disease  was  clearly  attributable  to 
vicissitudes  of  temperature  or  exposure  to  wet.  The  effects  of 
exposure  to  cold  are  well  exemplified  in  a  case  of  Dr.  Johnson, 
cited  by  Dr.  Dickinson  (loc.  cit.),  in  which  the  patient,  so  long 
as  he  remained  in  bed,  continued  free  from  the  paroxysms ;  but 
if  he  sat  up  and  got  chilled,  a  paroxysm  came  on.  In  a  case 
mentioned  by  Dr.  Pavy  ("Path.  Soc.  Trans.,"  vol.  xviii.  p.  157), 
the  patient  had  sometimes  averted  an  attack  by  going  indoors 
directly  he  felt  it  coming  on,  and  sitting  before  the  fire  and 
drinking  something  warm.  Sir  W.  Gull  believes  there  is' reason 
for  thinking  that  a  blow  or  injury  to  the  loins  may  be  the  cause 
of  this  affection ;  and  cites  the  case  of  a  young  lady  who  in 
getting  into  a  railway  carriage  fell  and  hurt  her  back,  shortly 
after  which  she  passed  dark  bloody-looking  urine,  in  which  he 
found,  on  careful  examination,  no  blood-corpuscles,  but  only 
the  granular  pigment  matter  of  disintegrated  blood-corpuscles. 
"Whilst  admitting  the  possibility  of  such  injuries  causing  haema- 
turia,  or  even  as  in  this  case  haemoglobinuria,  we  should,  how- 
ever, in  the  absence  of  further  evidence  on  the  point,  hesitate  to 
accept  them  as  a  cause  of  'paroxysmal  haemoglobinuria. 

Fleischer^  has  recorded  a  case  in  which  heat  and  cold  pro- 
duced no  effect,  but  the  paroxysms  were  always  brought  on  by 

1  Berlin,  klin.  Wochenschr.,  1881,  No.  47. 


PAROXYSMAL    H  y1<]  M  OG  I.O  Ji  I  N  U  K  I  A  .  167 

exercise.  In  the  rare  cases  wiiicli  occur  in  worneii,  Wolf  saw 
the  attack  brought  on  under  the  influence  of  menstruation  alone. 
Hfenioglobinuria  has  been  noticed  in  cases  of  Jiaynaud's  sym- 
metrical gangrene.  {See  Southey,  "  (Jlin.  Trans.,"  vol.  xvi. 
p.  167.) 

Murri  asserts  that  a  causal  relation  exists  between  syphilis 
and  paroxysmal  hiemoglobinuria.  He  found  a  history  of  sypliilis 
in  such  cases,  and  obtained  a  cure  by  the  use  of  antisyphilitic 
remedies. 

The  Pathology  of  the  disorder  is  very  obscure.  It  very  rarely 
ends  fatally,  and  the  few  post-mortem  examinations  w^hich  have 
been  obtained  have  given  no  clue  to  the  origin  of  the  disease. 
More  important  evidence  has  resulted  from  a  consideration  of 
hsemoglobinuria  produced  experimentally  in  animals,  and  from 
a  close  examination  of  the  paroxysm  as  it  occurs  in  man. 

Ponfick  found  that  the  hsemoglobinuria  caused  by  transfusion 
(p.  157)  was  accompanied  by  symptoms  closely  resembling  those 
of  the  paroxj'smal  affection  in  man.  In  the  artificial  affection, 
however,  he  found  that  there  was  a  solution  of  hsemoglobin  in 
the  blood-serum,  and  that  the  red  blood-corpuscles  showed  pecu- 
liar changes,  which  he  believed  were  produced  by  their  partial 
destruction.  Very  similar  changes  have  been  noticed,  in  the 
paroxysmal  affection  of  man.  If  during  the  paroxysm  the  serum 
obtained  from  a  blister  or  a  cupping-glass  be  examined,  in  many 
cases,  at  least,  it  will  be  found  to  contain  haemoglobin  in  solu- 
tion (Kiissner,^  Hayem,  and  others),  and  presumably  the  whole 
of  the  serum  of  the  body  is  in  the  same  condition.  The  micro- 
scopic examination  of  the  blood  (p.  160)  during  the  paroxysm 
has  also  revealed  changes  similar  to  those  described  by  Ponfick 
in  the  artificial  affection.  It  therefore  seems  probable  that  in 
paroxysmal  hiemoglobinuria  we  have  to  deal  with  a  condition 
in  which  the  blood-corpuscles  give  up  their  hsemoglobin  to  the 
surrounding  serum. 

We  know,  however,  from  the  researches  of  Bernard,  and 
Stokvis,  that  if  certain  forms  of  albumen  other  than  serum 
albumen  circulate  in  the  blood,  they  are  usually  filtered  off"  by 
the  kidneys  without  change,  and  appear  in  their  natural  con- 
dition in  the  urine.  So  then,  if  a  solution  of  haemoglobin  circu- 
late in  the  blood,  it  also  will  be  excreted  in  the  urine.^  Most 
observers  are  now  agreed  that  the  solution  of  the  hfemoglobin 
in  the  serum  precedes  its  appearance  in  the  urine,  and  that  the 
symptoms  of  kidney  affection,  which  are  sometimes  present,  are 
due  to  the  irritation  produced  by  the  passage  of  the  hemoglobin 

1  Centralbl.  f.  Med.  Wissensch.,  1883,  p.  820. 

2  Deutsch.  Med.  Wochenschr.,  No.  37,  1879. 

8  If  only  a  small  amount  of  haemoglobin  be  dissolved   in  the  serum,  it  may 
appear  in  the  urine  as  bile-pigment  (Cohnheim). 


168  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

through  those  organs.  Adams^  found  that  the  glomeruli  of  the 
kidney  alone  were  concerned  in  the  excretion  of  the  haemo- 
globin. In  Dr.  Dreschfeld's  case  of  poisoning  by  chlorate  of 
potash  (p.  157),  haemoglobin  could  not  be  seen  in  the  glomeruli, 
but  only  in  the  convoluted  tubes,  while  Ponfick^  has  lately  ghown 
that  all  the  secreting  parts  of  the  kidney  may  be  concerned  in 
the  process. 

A  few  observers,  and  amongst  them  Rosenbach  and  Lepine, 
still  hold  that  the  kidneys  are  primarily  affected,  and  that  in 
them  the  blood-corpuscles  are  destroyed,  and  their  haemoglobin 
reabsorbed  b.efore  it  can  circulate  in  the  blood-serum.  Rosen- 
bach  mainly  based  his  opinion  on  the  fact  (see  p.  160)  that  he 
observed  albumen  to  appear  in  the  urine  before  haemoglobin. 
There  are,  however,  only  few"  observations  in  which  such  dis- 
order of  the  kidney  function  was  found ;  while  Roux,^  working 
in  Cohnheim's  laboratory,  has  shown  that  the  amount  of  albu- 
men found  in  the  urine  of  an  ordinary  case  is  just  sufficient  to 
combine  with  the  amount  of  iron  present,  in  the  proportions 
necessary  to  produce  hsemoglobin,  and  that  hence  the  albumen 
present  is  probably  derived  entirely  from  the  haemoglobin. 

The  behavior  of  the  blood-corpuscles  has  been  investigated  by 
Ehrlich  and  Boas,  by  ligaturing  a  finger  and  then  placing  it  in 
ice-cold  water.  In  a  healthy  person  this  produced  no  change  on 
the  blood  of  the  finger,  but  in  a  person  who  was  subject  to 
hsemoglobinuria,  solution  of  haemoglobin  in  the  serum  was  ob- 
served, and  also  the  changes  in  the  blood-corpuscles  described  by 
Pontick  were  seen.  The  red  blood-corpuscles  were,  therefore, 
less  resistant  to  cold  than  in  the  normal  state.  Boas  also  showed 
that  they  were  more  easily  destroyed  by  the  electric  current  than 
were  healthy  corpuscles.*  It  seems  probable  that  a  similar  de- 
struction of  the  blood-corpuscles  may  take  place  in  the  exposed 
and  chilled  parts  in  the  paroxysmal  affection,  and  such  a  view  is 
supported  hj  Dr.  Southey's  cases  of  symmetrical  gangrene 
already  mentioned. 

The  cause  of  this  condition  of  the  blood-corpuscles  is,  as  yet, 
a  matter  of  pure  speculation.  According  to  Murri  the  cause  is 
to  be  sought  in  a  diseased  condition  of  the  blood-forming  organs, 
which  rendered  the  corpuscles  less  resistant  to  cold  and  to  car- 
bonic acid  than  normal  corpuscles  are.      Whether  primarily  or 

1  Dissertat.,  Leipzig,  1880. 

2  "  Verhandl.  des  Congresses  f.  inn.  Medic,"  Wiesbaden,  1883.  This  papermay 
also  be  consulted  for  information  concerning  the  so-called  "  Hsemoglobinasmia," 
which  precedes  the  change  in  the  urine.  The  author  shows  that  not  only  the 
kidneys,  but  also  the  spleen  and  the  liver  take  part  in  removing  the  haemoglobin 
from  the  circulation. 

3  Cohnheim's  Allgemeine  Pathologic,  ii.  p.  295. 

*  Only  one  experiment,  however,  was  successful,  and  further  evidence  is 
desirable. 


PAROXYSMAL    HAEMOGLOBIN  U  R I  A  .  l<-i9 

secondarily,  however,  the  nervous  system  must  be  an  active 
agent  in  producing  the  plienomena  of  the  [)aroxysm. 

There  seems  to  be  some  connection  between  this  affection  and 
ague,  but  its  precise  nature  is  as  yet  unknown.  Though  related, 
they  are  not  identical,  as  in  by  far  the  greater  number  of  cases 
there  has  been  neither  an  aguish  tendency  nor  any  evidence  of 
exposure  to  malarial  influences. 

Treatiment. — The  remedies  appropriate  to  the  ordinary  forms 
of  ha3maturia  have  been  found  wholly  inefficacious  in  this  dis- 
order. In  two  of  the  reported  cases  the  attacks  seem  to  have 
passed  off  without  any  medicinal  treatment,  simply  by  avoiding 
exposure  to  cold.  In  one  case,  recorded  by  Dr.  Dickinson,  cup- 
ping over  the  loins,  vapor  baths,  gallic  acid,  quinine,  iron  in 
various  forms,  were  tried  in  succession,  but  nothing  seemed  to 
affect  the  disorder;  "the  hemorrhage  always  ceased  on  the  re- 
moval of  the  cold  which  caused  it."  This  patient  had  an  inter- 
current attack  of  pneumonia,  after  which  he  passed  into  a 
typhoid  condition,  from  which  he  slowly  recovered  under  the 
use  of  stimulants,  and  afterwards  of  quinine  and  iron,  and  was 
discharged  well.  Dr.  Harley  gave  mercurials,  and  afterwards 
quinine  in  his  cases,  with  marked  benefit,  one  patient  having  re- 
mained free  from  the  paroxysms  for  four  years,  during  which  he 
was  under  observation.  Sir  "W.  Gull  gave  two  drachm  doses  of 
compound  tincture  of  cinchona  three  times  a  day,  with  benefit: 
the  patient  went  out  of  hospital  "convalescent.'"  Dr.  Hassall 
found  that  the  hemorrhage  was  considerably  restrained,  by 
giving,  night  and  morning,  a  powder  containing  tannic  and 
gallic  acids,  and  burnt  alum,  with  a  mixture  containing  quinine, 
sulphate  of  iron,  and  excess  of  sulphuric  acid  during  the  day. 
Dr.  Habershon  found  that  quinine  and  arsenic,  and  Dr.  Green- 
how  that  quinine  and  perchloride  of  iron,  and  afterwards  qui- 
nine and  syrup  of  the  iodide  of  iron,  with  iodide  of  potassium, 
had  the  effect  of  causing  the  urinary  symptoms  to  subside,  and 
the  patients  remained  free  from  attacks  for  several  months  after- 
wards, during  the  time  they  were  under  observation.  Dr.  Beale 
calls  attention  to  the  importance  of  giving  quinine  in  full  doses, 
not  less  than  six  grains,  in  order  to  combat  the  disorder  success- 
fully. Dr.  Begbie,  in  one  of  his  cases,  found  that  the  p)aroxysm 
did  not  recur  when  the  patient  took  twenty  grains  of  sal  ammo- 
niac three  times  daily.  During  the  paroxysm,  Dr.  Ritchie  found 
the  best  treatment  was  to  send  the  patient  to  bed,  apply  artifi- 
cial heat,  and  administer  warm  stimulating  drinks,  such  as  hot 
brandy  and  water.  The  evidence  generally  is  strongly  in  favor 
of  quinine  and  iron  as  the  most  effective  medicinal  agents.  In 
cases  where  a  syphilitic  taint  is  suspected,  it  would  be  well,  in 
view  of  Murri's  results,  to  prescribe  an  anti-syphilitic  treatment. 


170 


ABNORMAL    SUBSTANCES    IN    THE    UEINK, 


VII.— CANCEEOUS  AND  TUBERCULOIJS  MATTER  IN  UEINE. 

When  cancer  or  tubercle  of  any  part  of  the  urinary  tract  has 
t^one  on  to  ulceration,  the  urine  carries  away  with  it  some  of  the 
aisintegratecl  elements,  giving  rise  to  an  amorphous-looking 
grumous  deposit.  Sometimes  masses  of  the  morbid  tissue  as 
large  as  a  horse-bean  are  discharged  with  the  urine,  and  more  or 
less  blood  is  always  mixed  with  such  deposits. 

Very  great  caution  is  requisite  in  coming  to  a  conclusion  as  to 
the  cancerous  nature  of  cells  found  in  urine,  on  account  of  the 
great  similarity  between  the  irregular  transitional  forms  of  the 
epithehal  cells  lining  the  urinary  "passages,  and  the  cells  of  can- 
cerous growths.  Indeed  it  would  be  quite  unsafe,  in  such  a  case, 
to  rely  on  the  mere  form  and  size  of  individual  cells.  In  the 
annexed  drawing  (Fig.  34)  may  be  seen  the  diverse  shapes  dis- 

FiG.  34. 


Cell  from  the  urine  of  a  woman  with  fungus  of  the  bladder,     a,  Fibro-plastic  cells ; 
6,  b.  Cancer  cells  ;  c.  Epithelial  cells  ;  d.  Pus ;  e.  Blood. 


charged  with  the  urine  in  a  case  of  malignant  fungus  of  the 
bladder.  If  the  forms  be  compared  with  those  in  Figs.  23  and 
31  {g),  the  similarity  of  the  cells  will  appear  very  striking.  It 
is  more  safe  to  take  the  entire  character  of  the  deposit  into  con- 
sideration. It  may  be  described  as  a  thick,  dirty,  blood-stained 
sediment,  containing  abundance  of  blood-corpuscles,  mixed  with 
spindle-shaped,  oval,  and  irregular  cells.  Pus-corpuscles  may 
be  either  wholly  or  nearly  absent.  The  presence  of  shreds  or 
pieces  of  solid  tissue  appreciable  to  the  naked  eye,  should  be 
carefully  looked  for :  their  occurrence  is  almost  a  certain  proof 
of  the  existence  of  some  morbid  growth.  The  character  of  the 
deposit   generally,   and    especially   the  presence   of  numerous 


SPERM  ATORRIin-;  A.  1  71 

spindle-ahaped  (libro-plastic)  cells,  which  cannot  1)6  mistaken  for 
epithelial  elements,  indicate  clearly  that  soine  morbid  growth  or 
natural  tissue  is  being  l)roken  up.  The  collateral  s_yrn})toms  are 
then  generally  sufhcient  to  decide  whether  the  broken-up  tissue 
is  a  portion  of  the  natural  membrane  or  an  adventitious  growth. 
In  cancer  of  the  kidney  no  help  to  the  diagnosis  must  be  ex- 
pected from  the  character  of  the  urinary  deposit  (see  Cancer  of 
Kidney). 

The  discharge  associated  with  tuberculous  ulceration  differs 
from  that  of  a  cancerous  fungus  in  being  largely  purulent ;  in- 
deed, pus-corpuscles  are  usually  the  chief  appreciable  formed 
elements  in  the  urine  in  cases  of  tubercle  of  the  kidney  and 
bladder.  But  in  other  cases,  broken-down  cheesy  masses  may 
be  seen,  together  with  a  large  quantity  of  amorphous,  or  barely 
morphous  granular  debris  (for  the  discovery  of  tubercle  bacilli 
in  the  urine,  see  Tubercle  of  the  Kidney). 

It  follows,  of  course,  that  cancerous  and  tuberculous  masses 
may  exist  in  the  kidney,  or  beneath  the  mucous  membrane  of 
the  urinary  passages,  without  contributing  anything  to  the  stream 
of  urine.  It  is  only  when  ulcerated  that  their  elements  escape 
with  the  urine;  before  this  takes  place  they  may,  however,  give 
rise  to  copius  and  oft-repeated  hemorrhage. 

VIII.— SPEEMATOZOA  IN  UEINE— SPEKMATOKEHGEA. 

The  admixture  of  semen  with  the  urine  gives  rise  to  a 
mucous-looking  deposit.  When  in  large  quantity,  white  albu- 
minous flakes  and  masses  are  seen;  these  exhibit  a  viscid  con- 
sistence when  taken  up  with  the  pipette.  The  microscope 
reveals  the  existence  of  spermatic  filaments,  consisting  (Fig.  35) 

Fig.  35. 


Spermatozoa. 


of  a  minute  oval  head,  not  more  than  -^  ^  ^  ^^  ^  of  an  inch  in 
breadth,  and  a  long  whip-like  tail  of  extreme  delicacy.  The 
length  of  the  entire  filament  is  g^  of  an  inch. 


172  ABNORMAL    SUBSTANCES    IN    THE    URTNE. 

When  freshly  shed,  and  still  living,  they  exhibit  active  eel- 
like movements,  strongly  suggestive  of  volition  ;^  but  as  seen 
in  urine  they  are  always  motionless.  They  oifer  considerable 
resistance  to  disintegration,  and  may  sometimes  be  recognized 
in  decomposed  urine  which  has  been  kept  for  weeks. 

A  certain  quantity  of  seminal  fluid  necessarily  finds  its  wsij 
into  the  urine  of  both  sexes  after  coitus ;  also  into  the  urine  of 
men  after  involuntary  nocturnal  emissions. 

Involuntary  nocturnal  emissions  occurring  occasionally  in  the 
young  and  continent,  are  not  to  be  regarded  as  within  the  limits 
of  disease;  but  when  they  take  place  two  or  three  times  weekly 
or  oftener,  or  when  the  acts  of  defecation  and  micturition  are 
frequently  followed  by  a  glairy  discharge,  a  diseased  state  must 
be  acknowledged  to  exist;  and  one  also,  as  experience  proves, 
exceedingly  difficult  to  deal  with.  Whether  it  be  that  the 
mental  phenomena  observed  in  these  cases  are  altogether  sec- 
ondary to  the  genital  defect  may  well  be  questioned ;  but  it  is 
an  important — indeed  the  important — fact  in  relation  to  involun- 
tary seminal  discharges,  that  they  are  associated  with  a  deplor- 
able state  of  mind.  Much  of  this  is,  no  doubt,  owing  to  the 
prurient  eagerness  with  which  persons  so  afflicted  seek  satisfac- 
tion to  a  fatal  curiosity,  in  the  publications  of  unprincipled 
quacks,  who  lure  their  victims  with  libidinous  descriptions,  and 
afterwards  terrify  them  with  exaggerated  and  lying  pictures  of 
the  fate  which  awaits  them. 

But  there  is  a  danger  that  the  legitimate  practitioner  may 
come  to  look  upon  cases  of  this  class  too  lightly,  and  thus  be 
the  indirect  occasion  of  their  seeking  the  help  which  is  their 
injury. 

The  least  serious  cases  are  those  in  which  the  emissions  are 
solely  nocturnal.  As  long  as  the  complaint  is  confined  within 
these  limits  the  general  health  does  not  suffer,  and  the  mental 
state  is  seldom  gravely  disturbed.  Sometimes,  however,  indi- 
viduals of  fervid  imagination,  whose  health  is  from  any  cause 
below  par,  fix  upon  this  incident  (nocturnal  emissions)  with 
obstinate  tenacity,  and  hinge  their  ill-health  entirely  upon  it, 
when  in  reality  it  has  nothing  to  do  with  the  matter.  Persons 
go  on  for  years  subject  to  nocturnal  pollutions  without  any 
harm  resulting,  but  when  they  chance  to  become  dyspeptic,  or 
their  nervous  system  becomes  upset  by  overwork,  then  these 
emissions  loom  largely  to  their  imaginations,  and  they  connect 
them  with  their  failing  health. 

When  seminal  discharges  occur  daily,  and  accompany  or  fol- 
low defecation  and  micturition,  a  greater  departure  from  the 

'  Students  may  be  reminded  that  spermatozoa  are  not  really  independent  ani- 
mals, but  simply  the  escaped  contents  of  a  cell.  They  are  floating  cilia,  and 
resemble  the  oscillating  sperm-cells  of  the  antheridse  of  mosses. 


SrJiKMATORRIIfEA  173 

natural  state  is  betrayed ;  and  it  is  seldom  that  such  a  state  of 
things  continues  for  any  length  of  time  without  inducing  pallor, 
weakness,  want  of  zest  and  energy  for  work,  as  well  as  a  fidgety, 
vacillating,  and  sometimes  very  depressed  state  of  mind.  Never- 
theless, these  consequences  frequently  altogether  fail.  There 
was  recently  a  patient  under  my  care  at  the  lioyal  Infirmary — a 
ruddy,  strong-looking  young  man  of  six-and-twenty — who  had 
been  in  the  habit,  according  to  his  own  account,  for  the  last 
seven  years,  of  discharging  large  quantities  of  seminal  fluid 
almost  daily,  more  especially  with  micturition.  In  a  specimen 
of  his  urine  brought  to  me,  there  was  at  least  a  tablespoonful 
of  glairy  matter  having  the  microscopic  and  other  characters  of 
semen.  The  mental  state  was  certainly  shaken,  but  solely,  as  it 
appeared  to  me,  from  the  diligent  study  of  Mr.  Dawson's  book 
on  spermatorrhoea.  He  talked  with  a  sort  of  gloomy  satisfac- 
tion of  being  tired  of  life,  but  it  was  with  an  air  as  if  he  were 
repeating  a  lesson,  and  not  as  one  revealing  a  terrible  conviction. 

The  type  of  mental  disturbance  usually  associated  with  sper- 
matorrhoea, is  common  in  this  as  in  other  large  towns,  inde- 
pendently of  seminal  losses,  among  persons — chiefly  men  of 
business — whose  health  has  given  way  from  too  engrossing  ap- 
plication to  exciting  pursuits.  Such  persons  become  nervous, 
apprehensive  about  themselves  to  a  distressing  degree,  pusil- 
lanimous, subject  to  attacks  of  incomplete  syncope;  they  lose 
their  sleep  and  sometimes  their  appetite ;  there  is  some  real 
•emaciation  and  a  great  deal  of  fancied  wasting.  They  pour  into 
the  ears  of  their  medical  attendants  an  endless  variety  of  symp- 
toms, and  worry  them  beyond  the  most  tedious  hysterical 
women.  Such  patients,  although  often  men  of  middle  age,  or 
^t  least  beyond  their  first  youth,  and  fathers  of  families,  rarely 
fail  to  complete  the  catalogue  of  their  ailments  with  a  refer- 
ence to  what  they  conceive  to  be  some  anomaly  of  their  sexual 
functions. 

Involuntary  discharges  are  not  confined  to  youth  or  middle 
iige.  Men  advanced  in  years  are  sometimes  tormented  in  the 
same  way,  and  exactly  the  same  state  of  mind  is  observed  in 
them.  They  imagine  their  "substance"'  to  be  ebbing  from 
them,  and  their  virility  departing.  A  gentleman  over  sixty 
years  of  age,  the  father  of  a  family  of  married  daughters,  was 
so  concerned  about  a  slight  seminal  discharge  which  in  no  way 
affected  his  health,  that  he  forwarded  to  me  for  examination 
over  a  hundred  specimens  of  his  urine. 

In  the  Treatment  of  this  class  of  cases,  the  first  point  to 
establish  is  whether  the  trouble  of  the  nervous  system  is  the 
primary  phenomenon,  and  the  disturbance  of  the  sexual  func- 
tions only  an  insignificant  incident,  or  whether  the  seminal  losses 
are  in  such  frequency  and  quantit}'  that  they  may  be  regarded 


174  ABNORMAL    SUBSTAXCES    IN    THE     UKINE. 

as  having  a  hand  in  evolving  the  symptoms  complained  of.  The 
greater  majority  of  cases  belong  to  the  former  category ;  and 
indications  for  treatment  are  to  be  looked  for  in  the  general  state 
of  the  patient  and  the  circumstances  surrounding  him,  rather 
than  in  the  condition  of  the  sexual  functions.  If  it  appear,  after 
a  patient  sifting  of  the  actual  phenomena  and  the  past  history  of 
the  case,  that  the  seminal  emissions  must  be  regarded  as  the 
fundamental  ailment,  the  next  point  is  to  inquire  into  the  exist- 
ence of  any  local  cause  for  the  emissions.  The  irritation  of 
ascarides  or  hemorrhoids  sometimes  occasions  involuntary  dis- 
charges :  also  herpetic  eruptions  about  the  prepuce.  Lallemand 
enumerates  a  long  prepuce  as  contributing  to  the  same,  by  the 
lodgement  which  it  affords,  in  uncleanly  persons,  to  ofiensive  se- 
cretions. Whatever  be  the  local  cause  discovered,  its  immediate 
removal  is  of  course  the  first  step  in  the  treatment. 

In  the  absence  of  a  local  cause,  the  evil  can  usually  be  traced 
to  venereal  excesses,  masturbation,  and  the  reading  of  salacious 
literature.  Some  of  these  cases  are  very  difficult  to  deal  with. 
An  attempt  must  first  be  made  to  put  a  stop  to  the  practice 
which  is  the  cause  of  the  complaint.  The  further  treatment 
should  be  directed  to  improving  the  tone  of  the  muscular  system 
by  daily  ablutions  with  cold  water  or  brine,  by  sea  bathing,  regu- 
lated exercise,  change  of  air,  etc.  The  state  of  the  patient's 
mind  often  requires  that  the  time,  quantity,  and  material  of  the 
meals  shall  be  minutely  regulated.  The  diet  should  be  nourish- 
ing and  bland;  spices  and  condiments  should  be  avoided.  Malt 
liquors  and  the  lighter  wines  are  to  be  cautiously  employed;  the 
quantity  must  be  judged  by  their  efiects.  Any  quantity  which 
produces  flushing  of  the  face  is  too  much.  An  opiate  sometimes 
renders  good  service  by  securing  a  good  night's  rest.  Astrin- 
gent and  ferruginous  tonics  offer  valuable  aid  to  the  hygienic 
treatment.  Tincture  of  the  muriate  of  iron  has  appeared  tome 
to  produce  a  better  effect  than  any  other  preparation,  A  blister 
to  the  perineum  has  sometimes  seemed  to  diminish  the  emissions. 
In  cases  of  inveterate  masturbation,  Mr,  Hilton  found  that  he 
could  invariably  put  a  stop  to  the  practice  by  applying  a  strong 
solution  of  iodine  or  blistering  fluid  to  the  penis  so  as  to  render 
the  organ  too  sore  for  manipulation.^ 

Lallemand  recommends  the  local  application  of  nitrate  of 
silver  to  the  orifices  of  the  ducts  of  the  vesiculse  seminales  by 
means  of  his  porte-caustique,  I  cannot  say  that  I  have  ever  seen 
cases  in  which  this  severe  proceeding  seemed  justifiable.  It  must 
be  remembered  that  it  is  not  without  danger.  Dr.  Bird  relates 
an  instance  in  which  a  dangerous  cystitis  was  produced  in  a 
healthy  person  by  the  local  application  of  the  solid  nitrate  of 

1  Lancet,  1863,  II,  123, 


MICRO-ORGANISMS    IN    THE    URINP:.  175 

silver  in  this  manner.  l)v.  Chambers  has  communicated  another 
and  more  untoward  example,  in  which  death  followed  the  appli- 
cation of  an  irritant  ointment  \)y  means  of  a  catheter  in  a  case 
of  imaginary  spermatorrhcjoa.' 

Dicenta,  B.  Schulz,^  and  Benedikt,'''  speak  in  high  terms  of  the 
constant  galvanic  current.  Schulz  directs  the  current  to  be 
transmitted  along  the  vertebral  column  for  one  or  two  minutes, 
and  repeated  three  or  four  times  a  week.  Twenty  or  thirty 
Daniel's  elements,  of  medium  size,  should  be  used  ;  the  positive 
pole  should  be  applied  to  about  the  fifth  dorsal  vertebra,  and  the 
negative  to  the  sacrum  or  perineum.  My  colleague,  Dr.  Dresch- 
feki,  has  published  an  account  of  three  cases  successfully  treated 
by  the  application  of  the  constant  current  twice  a  week  to  the 
lumbar  region.     ("Practitioner,"  1874,  p.  360.) 

IX.— MICKOOKGANISMS  IN  THE  UEINE. 

The  microorganisms  met  with  in  the  examination  of  the  urine 
may  be  classed  into  three  categories — namely:  Torulaceous 
Vegetations,  Sarcina,  and  the  various  forms  of  Bacteria. 

I. — Torulaceous  Vegetations  (Saccharomtces). 

Torulse  appear  in  the  urine  after  emission  only.  They  have 
not  been  detected  in  the  perfectly  fresh  secretion — but  are  ex- 
clusively derived  from  germs  which  gain  access  to  the  urine  and 
grow  in  it  after  it  has  left  the  urinary  passages.  They  appear 
at  first  as  minute  oblong  cells  (sporules),  either  lying  separate, 
or  strung  together  into  short  chains.  Presently  they  elongate 
into  transparent  hollow  threads  wdiich  divide  and  interlace  into 
a  fleecy  cloud  (thallus).  The  most  common  are  the  sporules  of 
the  blue  and  brown  moulds  [Penicilimn  glaucum  and  Aspergillus 
niger)  and  of  the  yeast  plant  [Saccharomyces  Cerevisice).  After  a 
few  days'  growth  the  two  former  ascend  to  the  surface  and  form 
patches  of  mould,  constituting  the  aerial  fructification  of  these 
vegetations,  Torulje  are,  strictly  speaking,  extraneous  impuri- 
ties in  the  urine;  and  they  are  only  of  importance  from  their 
liability  to  be  confounded  with  blood-corpuscles  or  other  objects 
derived  from  the  urinary  passages.  Torulje  are  distinguished 
from  blood-disks  by  the  great  difl:erence  of  size  among  the  in- 
dividual cells  (Fig.  36);  the  presence  of  a  nucleus  in  the  larger 
sporules,  their  tendency  to  assume  an  elongated  or  oval  form; 
and  the  indications  of  budding  and  commencing  formation  of  a 

1  Lancet,  1861,  p.  582. 

^  Year  Book,  1863,  p.  300.     Reports  on  Surgery  also. 

^  Elektrotherapie,  Vienna,  1868,  p.  447. 


176 


ABNORMAL    SUBSTANCES    IN    THE    URINE. 


thallus.     Torulse  appear  in  the  urine  sometimes  in  a  few  hours 
after  emission — more  commonly  after  the  lapse  of  a  day  or  two. 


Fig.  36. 


Torulse  in  urint. 


<S>   SB 


They  require  an  acid  reaction  for  their  free  growth ;  and  they 
cease  to  multiply,  and  finally  perish,  when  the  urine  becomes 
ammoniacal. 

2. — Sarcina. 

Since  Heller  and  Mackay,  in  1848,  first  discovered  sarcinse  in 
urine,  they  have  been  observed  by  Johnson,  Beale,  Welcker, 
Munk,  Begbie,  and  myself.     The   seat 
Fig.  37.2  of  production  of  this  vegetation  is  proba- 

bly the  bladder;    and  it   is  discharged 
®  with  the  urine,  sometimes  in  great  quan- 

tities, and  forms  a  grayish-white  amor- 
phous-looking deposit.    It  consists  of  the 
same  elements  as  the  sarcina  ventriculi 
o  (of  Goodsir),  and  is  usually  regarded  as 

«-  g,  o  the   same   species.      Both    the    cubical 

«  o  masses    and    their   component   particles 

^  are,  however,  smaller  than  those  of  the 

^        e  gastric     sarcina,    and     Rossmann     and 

«■  "*  Welcker^  consider  these  differences  suf- 

saroinas  in  urine.  ficicut  to  cstablish  a  spccific  distiuctiou. 

It  seems  more  probable,  however,  that 
the  differences  in  the  habitat  and  conditions  of  growth  are  suf- 
ficient to  account  for  the  diversity  of  size.  Dr.  P.  Munk^  has 
shown  that  one  of  the  points  relied  on  by  Welcker,  namely,  the 
absence  (in  urinary  sarcina)  of  cubes  containing  more  than  64 

1  Ueber  Sarcina  im   Urine  des  Menschen.      Henle  and    Pfeuf.    Zeitsch.    3tte 
K.  Bd.  V.  199. 

^  After  Welcker,  Henle  and  Pfeufer's  Zeitsch.,  Bd.  V.  Taf.  x. 
^  Ueber  Harnsarcine — Archiv  f.  Path.  Anat.  1861,  p.  570. 


MICKO-OKGANISMS    IN    'I'llE    UlilNii.  177 

particles,  is  not  constant.  Munk  found  cuIjcs  of  fjll  [(articles. 
In  some  vomited  matter  sent  to  me  for  examination  by  Dr. 
Scowcroft,  of  Southport,  1  detected  small-sized  sarcinte  mixed 
with  those  of  ordinary  dimensions. 

This  curious  vegetation  is  generally  associated  with  some 
disorder  of  the  urinary  organs  (renal  pains,  |)ainful  micturition, 
vesical  catarrh,  etc.).  It  grows,  or  at  least  exists,  both  in  acid 
and  ammoniacal  urine.  In  Munk's  case  the  fungus  grew  in 
great  quantities  during  the  summer  months,  and  disappeared 
almost  wholly  in  the  winter  months ;  and  this  was  the  more 
remarkable  as  the  patient  (who  was  paraplegic)  kept  his  bed 
continuously  from  year  to  year.  Dr.  Begbie's  patient'  suffered 
from  lumbar  pains  and  frequent  micturition,  together  with 
hypochondriacal  and  dyspeptic  symptoms.^  In  the  case  seen  by 
me,  the  patient — a  merchant  about  sixty  years  of  age — was  suf- 
fering from  long-standing  chronic  cystitis,  due  to  enlarged 
prostate. 

No  treatment  yet  tried  has  had  any  appreciable  effect  in 
checking  the  growth  of  sarcinte  in  urine. 

3. — Bacteria  (Bacteruria). 

Urine,  like  other  organic  fluids,  when  exposed  to  the  contact 
of  air-dust  or  of  ordinary  water,  passes  sooner  or  later  into  a 
state  of  decomposition.  It  is  then  found  to  swarm  with  bac- 
teria. The  organisms  under  these  circumstances  gain  access  to 
the  urine,  and  grow  in  it  after  it  has  left  the  body.  But  there 
are  also  conditions  in  which  the  urine  contains  bacteria  at  the 
moment  of  emission.  In  these  cases  the  organisms  must  have 
grown  and  multiplied  in  the  urine  during  its  sojourn  in  the 
urinary  passages.  These  cases  may  be  conveniently  embraced 
under  the  general  heading  of  Bacteruria.  But  inasmuch  as  the 
bacteria  discharged  with  the  urine  are  of  various  kinds  or 
species,  and  as  the  different  species  affect  the  urine  in  quite 
different  ways,  the  resulting  symptoms  also  difiJer  greatly  both 
in  degree  and  in  kind.  Certain  kinds  of  bacteria  affect  the 
composition  of  the  urine  very  slightly,  or  not  at  all;  others 
again  rapidly  break  up  its  chief  constituent,  urea,  into  carbonate 
of  ammonia,  and  thereby  introduce  into  the  previously  bland 
secretion  a  fiery  irritant,  which  is  apt  to  light  up  a  dangerous 
inflammation  of  the  urinary  mucous  membrane.  For  these 
reasons  it  is  necessar}'  to  divide  cases  of  bacteruria  into  a  certain 
number  of  groups  or  categories.  How  many  such  groups  it 
may  be  eventually  necessary  to  establish  I  cannot  say — the  sub- 
ject is  as  yet  new,  and  the  field  of  inquiry  only  partially  ex- 

1  Edin.  Med.  Journ.  1856-7. 

'^  iSee  also  a  paper  by  Heller — "Wien.  Med.  Presse,  xi.  p.  13. 
12 


178  ABNORMAL    SUBSTANCES    IN"    THE    URINE. 

plored.  The  cases  which  have  hitherto  fallen  under  my  obser- 
vation appear  to  warrant  a  division  into  four  groups ;  namely, 
(1)  eases  in  which  the  presence  of  bacteroid  organisms  is  asso- 
ciated with '  incipient  putrefactive  changes  in  the  urine;  (2) 
cases  associated  with  ammoniacal  fermentation  of  the  urine ; 
(3)  cases  in  which  some  of  the  common  forms  of  bacteria  are 
present  without  decomposition  of  the  urine ;  (4)  cases  in  which 
micrococcus  chains  are  voided  with  the  urine.  A  good  many 
examples  of  bacteruria  are  mixed  cases — cases  in  which  more 
than  one  form  of  bacteria  coexist  in  the  urine — but  the  above 
scheme  of  classification  may  be  provisionally  adopted ;  and  I 
propose  to  devote  a  separate  notice  to  each  group. 

Group  I.  Bacteruria  Associated  with  Incipient  Putre- 
factive Changes  in  the  Urine. — This  form  of  bacteruria  is 
very  common.  The  urine  is  more  or  less  opalescent  when 
voided ;  it  is  feebly  acid,  neutral  or  feebly  alkaline.  When 
examined  under  the  microscope  it  is  found  to  contain  bacteria 
in  active  motion.  The  kinds  of  bacteria  present  in  these  cases 
are  the  common  forms  found  in  decomposing  organic  fluids,  of 
which  the  least  known  is  the  Bacterium  termo  (Fig,  38).  The 
urine  on  standing  does  not  recover  its  transparency ;  on  the 
contrary,  the  turbidity  tends  to  increase,  and  the  urine  passes 
on  pretty  quickly  to  decomposition.  This  condition  is  accom- 
panied by  few  or  no  symptoms ;  there  may  be  a  little  heat  about 
the  genitals,  or  a  slight  undue  frequency  of  micturition — but 
for  the  most  part  no  complaint  is  made.  This  condition  is  not 
unfrequent  in  women  of  weak  health  suffering  from  leucorrhcea, 
and  is  common  among  men  who  have  sufi:'ered  from  stricture, 
and  who  have  frequently  used  catheters  or  bougies.  The  aiFec- 
tion  is  in  itself  of  no  importance,  and  may  persist  for  years 
without  requiring  attention;  but  it  assumes  a  graver  significance 
if,  as  I  have  reason  to  believe,  it  renders  the  subjects  of  it  liable 
to  the  next  form  of  bacteruria  which  is  associated  with  ammo- 
niacal urine. 

GrROUP  II.  Bacteruria  with  Ammoniacal  Fermentation  of 
THE  Urine. — This  condition  always  involves  the  patient  in 
serious  suffering  and  danger.  The  change  which  occurs  in  the 
urine  in  these  cases  is  the  transformation  of  urea  into  carbonate 
of  ammonia.  The  chemical  nature  of  this  change  has  been 
already  explained  [see  p.  83).  One  molecule  of  urea  with  two 
molecules  of  water  become  two  molecules  of  carbonate  of  am- 
monia, COiNH^)^  +  2H2O  =  (NHJ2CO3.  The  transformation 
is  an  example  of  bacterial  fermentation.  Pasteur  believes  that 
the  change  is  due  to  the  action  of  a  minute  spherical  bacterium 
to  which  Cohn  has  given  the  name  of  micrococcus  urecB.  This 
organism  consists  of  excessively  minute  round  particles,  lying 


MIGKO-ORG-ANTSMS    IN    THE    URINE.  179 

free  and  in  active  movement,  or  strung  together  into  short 
chains  of  two,  three,  or  four  elements  each  {see  Fig,  88,  h). 

Ammoniacal  bacteruria  is  apt  to  arise  in  old  stricture  cases, 
in  cases  of  stone  in  the  bladder,  after  operative  procedures, 
whether  lithotomy  or  lithotrity,  in  cases  of  enlarged  prostate, 
paraplegia,  morbid,  growths  in  the  bladder,  and  in  all  conditions 
in  which  the  organ  is  unable  to  empty  itself  completely,  or 
which  require  the  frequent  use  of  instruments. 

In  these  two  groups  of  cases  the  offending  organism  gains 
access  to  the  bladder  by  the  urethra — at  least  in  the  over- 
whelming majority  of  cases.  In  the  female  the  short  and  com- 
paratively wide  urethra  oiFers  obvious  facilities  to  wandering 
bacteria  to  penetrate  into  the  viscus  from  the  external  genitals. 
In  the  male  the  long  and  narrow  urethra  forbids  this  mode  of 
entrance  in  the  normal  state.  But  in  cases  of  gonorrhoea,  or 
other  type  of  urethritis,  in  which  the  passage  is  lined  with  a 
continuous  layer  of  purulent  discharge,  it  is  quite  easy  to  under- 
stand that  along  this  purulent  tract  bacteria  may  breed  their 
way  up  into  the  bladder.  In  a  good  many  cases  the  infective 
organisms  steal  in  with  the  instruments,  which  always  come 
into  use,  sooner  or  later,  in  all  kinds  of  vesical  trouble.  A  dirty 
catheter  is  a  most  efficient  infective  agent.  It  must  not,  how- 
ever, be  overlooked  that,  in  states  of  depressed  vitality,  septic 
germs  may,  occasionally  at  least,  find  their  way  into  an  ailing 
organ  or  tissue  by  the  channels  of  the  circulation.  Such  a  mode 
of  intrusion  of  bacteria-germs  into  the  bladder  in  cases  of  para- 
plegia seems  highly  probable. 

G-Roup  III.  Bacteruria  avithout  Decomposition  of  the 
Urine. — Judging  by  my  own  experience,  this  is  a  condition  far 
from  infrequent.  The  organisms  which  are  present  in  the  urine 
in  these  cases  are  short  moving  rods  and  micrococci.  I  am  not 
sure  that  the  organisms  are  always  of  the  same  species,  but  they 
are  evidently  neither  the  bacterium  termo  nor  the  micrococcus 
urese,  inasmuch  as  they  produce  no  change  in  the  chemical  con- 
stitution of  the  urine.  In  some  examples  the  organisms  resemble 
the  Bacillus  suhtilis  (of  Cohn),  and  the  short  rods  are  found 
accompanied  with  long  slender  threads  {see  Fig.  38,  c  and  d). 

The  character  of  the  urine  in  this  group  ditfers  widely  from 
that  in  the  two  previous  groups.  In  decomposing  urine  (Groups 
I.  and  II.)  the  turbidity  is  persistent,  and  the  organisms  go  on 
multiplying  in  it  after  it  has  left  the  bod}'.  But  in  the  group 
now  under  consideration,  the  urine,  although  opalescent  when 
voided,  becomes  clear  on  standing,  and  the  organisms,  together 
with  the  other  formed  elements  (pus,  etc.),  subside  to  the  bottom 
of  the  vessel.  The  supernatant  urine  continues  transparent  and 
acid  for  many  days,  and  the  organisms  show  no  signs  of  multi- 
plying.    Indeed,  the  urine  exhibits  less  tendency  to  decomposi- 


180  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

tion  than  ordinarily  healthy  urine,  and  remains  clear  and  acid 
for  seven  or  ten  days.  Even  when  the  urine  is  kept  in  the  warm 
chamber  at  blood-heat  the  organisms  do  not  multiply.  All  this 
leads  to  the' inference  that  in  this  kind  of  bacteruria,  the  seat  of 
growth  of  the  organisms  is  not  the  urine  itself,  but  some  portion 
of  the  surface  of  the  urinarj-  mucous  membrane. 

Fig.  38. 

•!  \> 


a 


Various  kinds  of  bacteroid  organisms  found  in  the  freshly  voided  urine,  a.  Bacterium  termo  ; 
h.  Micrococcus  urea3  ;  c  and  rf,  other  bacterial  forms — not  identified  \vith  certainty  as  belonging  to  any 
of  the  known  species  of  bacteria. 

The  symptoms  which  are  associated  with  this  form  of  bac- 
teruria are  frequent  and  painful  micturition,  and  pains  about 
the  neck  of  the  bladder.  They  vary  greatly  in  intensity — rising 
and  falling  apparently  in  unison  with  the  increasing  or  lessening 
swarms  of  bacteria  discharged  in  the  urine. 

This  form  of  bacteruria  seems  to  be  controlled  in  an  important 
degree  by  the  internal  administration  of  full  doses  (30  grains 
twice  a  day)  of  salicylate  of  soda. 

In  the  last  four  years  I  have  met  with  a  considerable  number 
of  cases  belonging  to  this  group.  The  two  following  may  serve 
as  typical  examples : 

Case  1. — -A  retired  professional  man  about  fifty  years  of  age  fell  on 
his  hip  in  February,  1881.  As  the  hip  continued  painful,  a  strong  solu- 
tion of  iodine  was  applied  to  it,  which  produced  vesication.  Four  or 
five  days  afterwards  there  arose  a  violent  irritation  of  the  bladder.  It 
was  conjectured  that  this  might  be  due  to  a  congested  state  of  the  pros- 
tate, and  on  that  view  blistering  fluid  was  applied  freely  to  the  perineum. 
This  was  immediately  followed  by  an  aggravation  of  the  bladder  symp- 
toms. Micurition  became  excessively  frequent  and  painful.  These 
symptoms  persisted  with  severity  for  a  period  of  two  months,  and  then 


MICRO-ORGANISMS    IN    THE    U  R  1  N  K  .  181 

began  to  abate  under  the  use  of  warm  baths.  Neither  bl(jofl  nor  alhu- 
men  appeared  in  the  urine  during  all  this  time,  and  the  reaction  of  the 
secretion  was  always  acid. 

When  he  consulted  nie,  three  months  after  the  accident,  the  same  symp- 
toms continued  in  a  mitigated  degree.  He  voided  urine  in  my  presence. 
It  was  opalescent,  and  swarmed  with  bacteria,  but  it  was  sharply  acid.  A 
j)ortion  set  aside  in  a  urine-glass  became  quite  transj)arent  in  twenty-four 
hours  and  let  fall  a  deposit  consisting  of  bacteria  rods  mixed  with  pus- 
corpuscles.  This  urine  remained  transparent  and  acid  for  seven  days  in 
a  warm  room.  Three  other  specimens  subsequently  examined  behaved 
exactly  in  the  same  way.  Thirty  grains  of  salicylate  of  soda  were  pre- 
scribed to  be  taken  twice  a  day.  In  less  than  a  week  the  symptoms 
subsided,  and  the  bacteria  disappeared  from  the  urine.  In  the  subse- 
quent year  the  symptoms  returned,  and  continued  with  considerable 
violence  for  some  weeks.  The  urine  was  again  found  to  swarm  with 
bacteria  and  to  present  the  same  characters  as  before.  This  second 
attack  was  also  cut  short  in  a  few  days  by  the  salicylate  of  soda. 

Case  2. — A  merchant,  then  aged  40,  consulted  me  in  1881,  suffering 
from  severe  vesical  catarrh.  The  urine  passed  in  my  presence  was  found 
to  be  laden  with  actively  moving  bacteria,  together  with  pus-corpuscles 
and  a  few  blood-disks.  (This  man  had  suffered  from  cystitis  ten  years 
before,  but  in  the  interval  had  maintained  fair  health,  although  he  had 
never  been  quite  free  from  urinary  trouble.)  The  reaction  of  the  urine 
was  acid ;  and  it  showed  the  same  remarkable  indisposition  to  pass  into 
decomposition  as  in  the  preceding  case.  This  man  has  visited  me  from 
time  to  time  until  the  present  year  (1884).  He  has  suffered  from  several 
recurrences  of  the  bladder  trouble  —  the  urine  on  these  occasions  is 
always  of  the  same  character  and  the  attacks  are  always  relieved  by  the 
use  of  thirty-grain  doses  of  the  salicylate  of  soda.  But  the  urine  never 
becomes  absolutely  free  from  bacteria — and  exposure  to  cold,  worry,  or 
excessive  fatigue  invariably  brings  on  a  recrudescence  of  the  symptoms. 

Ill  neither  of  these  cases  had  an  instrument  ever  been  passed 
into  the  bladder,  and  it  must  be  regarded  as  probable  that  the 
organisms  had  originall}^  obtained  access  into  the  bladder  by 
the  circulation.  In  the  majority  of  cases  of  this  group  which  I 
have  encountered,  instruments  had  been  used  at  some  time  or 
other,  and  it  was  therefore  impossible  to  be  sure  whether  the 
organisms  had  not  been  introduced  by  their  means. 

A  longer  acquaintance  with  cases  belonging  to  this  group  — 
that  is,  cases  where  bacteria-forms  are  discharged  with  the  urine 
without  there  being  any  decomposition  of  the  secretion — has 
convinced  me  that  the  organisms  present  in  diiferent  cases  are 
not  of  one  uniform  type,  and  that  in  some  examples  two  or  more 
distinct  species  are  growing  side  by  side  in  the  bladder.  The 
different  microscopic  character  of  the  organisms  is  sufficient  to 
substantiate  this  in  some  instances  ;  but  the  microscope  is  a  very 
imperfect  guide  in  the  study  of  specific  differences  among  bac- 
teria.    More  light  will  be  thrown   on  the    subject   when    the 


182  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

several  kinds  encountered  in  urine  have  been  sifted  by  the 
method  of  artificial  cultivation.  In  this  branch  of  the  inquiry 
I  have  made  but  little  progress,  and  I  should  like  to  invite 
observers  with  more  leisure  than  myself  to  enter  the  field. 

Group  IY.  Micrococcus  Chains  in  the  Urine  without  De- 
composition.— Although  I  have  met  with  but  one  example  of  this 
group,  the  organism  found  in  the  urine  was  so  distinctive  that  it 
warrants  me  in  separating  this  form  of  bacteruria  from  the 
remainder.  I  have  also  succeeded  in  cultivating  the  organism 
artificially  in  a  state  of  absolute  isolation  from  all  other  organ- 
isms. The  patient  was  a  retired  merchant,  68  years  old.  At 
the  age  of  sixteen  he  went  to  Rio  Janeiro  and  stayed  there  fifteen 
years.  He  then  went  to  India  for  one  year.  For  the  last 
twenty-eight  years  of  his  life  he  resided  in  England.  With  the 
exception  of  a  few  slight  attacks  of  gout  he  enjoyed  good  health 
until  within  three  years  of  his  death.  At  this  period  he  began 
to  suffer  from  recurrent  attacks  of  hseraaturia.  These  attacks, 
at  first  slight  and  occurring  at  long  intervals,  became  gradually 
more  severe  and  more  frequent.  At  length  the  bleeding  became 
continuous;  violent  cystitis  intervened  and  finally  the  patient 
died  exhausted.  After  death  three  soft  bleeding  polypoid 
growths  were  found  in  the  bladder.  It  is  not  necessary  for  the 
present  purpose  to  enter  more  fully  on  the  clinical  history  of  the 
case  nor  to  recount  the  various  plans  of  treatment  adopted.  I 
first  saw  the  case  Avith  my  friend  Dr.  Ransome,  of  Bowden,  in 
the  spring  of  1881,  and  we  watched  it  closely  until  its  termin- 
ation in  April,  1882.  During  the  progress  of  the  illness  the 
urine  had  been  repeatedly  examined,  with  no  other  result  than 
the  finding  of  blood-corpuscles  and  leucocytes;  but  in  the  mid- 
dle of  July  I  detected  something  I  had  not  observed  before.  I 
saw  in  the  deposit  a  number  of  long  delicate  beaded  threads. 
In  all  my  experience  of  urinary  examinations  I  had  not  seen 
anything  like  them  in  the  fresh  urine.  After  this  date  the  urine 
was  examined  many  scores  of  times,  and  the  same  beaded  threads 
were  invariably  found  in  large  numbers  in  every  specimen.  The 
urine  was  generallj^  acid;  and  it  showed  no  unusual  tendency  to 
decomposition.  It  contained  no  other  organisms  except  the 
beaded  threads  until  a  late  period  of  the  case,  when,  as  a 
sequence  to  the  use  of  injections  into  the  bladder,  bacterium 
termo  and  the  micrococcus  ureae  made  their  appearance.  This 
conjunction  evidently  hampered  the  growth  of  the  beaded 
threads,  and  they  nearly  vanished  from  the  urine  before  the 
termination  of  the  case.  The  following  account  of  these  fila- 
ments was  gathered  from  repeated  examinations  of  different 
samples  of  the  urine,  and  of  the  cultivated  organism.  To  the 
naked  eye  the  fresh  urine  looked  very  much  like  that  from  an 
ordinary  case  of  acute  Bright's  disease.   It  had  a  smoky  appear- 


MIGKO-ORG  ANISMS    IN    THE    UKTNE, 


183 


auce,  and  deposited  on  standing  a  loose  reddish-brown  sediment. 
The  sediment  consisted  of  little  soft  brownish  masses  or  flakes 
mixed  with  blood.  Under  the  microsco})e  these  flakes  were 
found  to  be  composed  of  leucocytes  or  pus-like  corpuscles  inter- 
mixed with  blood-disks.  In  these  flakes  the  beaded  threads 
were  seen,  twisted  and  turned  in  every  direction,  and  forming 
an  inextricable  tangle  of  threads  running  in  and  out  among  the 
corpuscles.  In  perfectly  fresh  samples  the  filaments  were  found 
exclusively  in  these  leucocyte-flakes;  but  after  the  urine  had 
been  kept  awliile  the  flakes  broke  up  more  or  less,  and  then 
detached  fragments  of  the  threads  were  seen  scattered  about  in 
the  field  of  the  microscope.  With  a  magnifying  power  of  .500 
diameters  the  threads  were  seen  to  consist  of  moniliform  fila- 
ments of  extreme  delicacy  and  regularity  of  structure  (see  Fig. 
39).     Their  width  measured  from  a  tenth  to  a  fifteenth  part  of 


Fig.  39. 


Beaded  threads — or  mici-ococcvis  chains— from  the  freshly-voided  urine  of  the  case  described 
in  the  text — mixed  with  leucocytes  and  Wood-disks. 


the  diameter  of  a  blood-disk.  Their  length  varied  greatly. 
Some  were  so  long  that  they  stretched  right  across  and -far 
beyond  the  field  of  microscopic  vision ;  but  they  were  for  the 
most  part  so  twisted  and  turned  on  themselves  that  it  was 
impossible  to  gain  a  precise  idea  of  their  length.  Under  an 
immersion  lens  and  with  good  illumination  the  filaments  were 
resolved  into  a  row  of  minute  spheres  appiosed  end  to  end  like 
a  string  of  beads. 

The  organism  was  found  to  be  easily  susceptible  of  artificial 


184  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

cultivation,  in  either  highly  diluted  albuminous  urine  or  in 
filtered  beef-tea.  When  a  drop  of  the  fresh  urine  was  intro- 
duced into  a  sterilized  flask  containing  beef-tea — and  the  flask 
was  placed  in  the  warm  chamber  at  blood-heat — the  new  growth 
soon  made  its  appearance.  In  from  three  to  six  hours  light 
fleecy  specks  were  seen  scattered  through  the  transparent  me- 
dium. In  the  course  of  another  hour  or  two  these  gathered 
themselves  together  into  a  voluminous  soft  cloud.  After  this 
no  further  change  occurred  —  the  process  of  growth  seemed 
ended.  From  the  first  cultivation  a  second,  a  third,  and  so 
forth,  up  to  a  sixth  cultivation  were  easily  obtained  in  a  state 
of  perfect  purity,  and  without  exhibiting  the  slightest  modifica- 
tion of  form. 

"When  a  portion  of  the  cloudy  mass  was  placed  on  a  glass 
slide  the  patch  had  a  curious  white,  shiny,  satiny  appearance — 
and  it  resolved  itself  under  the  microscope  into  a  close  felt 
or  tangle  of  most  delicate  beaded  filaments  of  endless  length, 
exactly  resembling  those  found  in  the  fresh  urine.  The  newly 
grown  terminal  portions  of  a  filament  were  a  little  slenderer 
than  the  older  portions,  and  the  component  molecules  were 
more  perfectly  spherical.  In  the  voider  portions  the  molecules 
had  a  squarer  contour — as  if  from  mutual  compression.  The 
filaments  did  not  appear  to  divide  or  branch  in  any  degree. 
They  appeared  to  multiply  by  throwing  oft'  single  molecules  or 
short  pieces  from  their  growing  ends,  which  lengthened  into 
new  chains.  .  I  could  detect  no  signs  of  an  enveloping  sheath. 
The  separate  molecules  were  evidently  tightly  hung  together  on 
their  filaments — and  the  younger  threads  could  be  seen  to  move 
and  twist  with  a  curious  uneasy  springy  motion  as  they  adjusted 
themselves  under  the  pressure  of  the  covering-glass.  There 
was,  however,  no  real  motility  of  the  filaments.  The  filaments 
took  the  aniline  dyes  readily  and  yielded  beautiful  microscopical 
objects  when  mounted  in  Canada  balsam. 

This  organism  must  be  very  rare.  Though  constantly  on  the 
watch  for  it  during  the  past  three  years  I  have  not  encountered 
a  second  example.  I  scarcely  think  that  the  organism  had  any 
thing  to  do  with  the  disease  of  which  the  patient  died.  At  any 
rate  I  have  failed  to  find  it  in  the  urine  of  other  patients  suffer- 
ing from  undoubted  polypoid  growths  in  the  bladder.  How 
did  the  organism  gain  access  to  the  bladder?  As  the  patient 
had  been  more  than  once  sounded  for  stone  before  the  organism 
was  detected  in  the  urine,  the  germs  of  it  might  be  supposed  to 
have  been  introduced  with  the  instruments — but  it  is  difficult  to 
reconcile  this  view  with  the  extraordinary  rarit}-  of  the  organism. 
Bacteruria  after  the  use  of  instruments,  is  an  every-day  occur- 
rence— the  urine  in  such  cases  is  being  constantly  subjected  to 


ALBUMEN    IN    THE    U  K  ]  N  E  .  385 

minute  microscopic  examination  ]>y  competent  oljKcrverH— -and 
yet  this  very  distinctive  organism  has  only  l)een  seen  iji  a  single 
case.^ 

X.— ALBUMEN  IN  THE  UEINE. 

Albumen  is  not  discoverable,  even  by  the  most  delicate  direct 
testing,  in  the  perfectly  normal  urine;  but  it  constitutes  the 
most  common  and  most  important  of  the  abnormal  ingredients 
found  in  disease.  Its  presence  in  the  urine  is  due  to  several 
difterent  conditions,  so  that  the  fact  itself  yields  only  a  vague 
information;  but  when  correctly  interpreted  it  furnishes^  key 
to  certain  grave  pathological  states  which  would  otherwise  re- 
main in  great  obscurity."  The  kind  of  albumen  found  in  morbid 
urines  is  serum.- album ev,  and  in  clinical  testing  our  main  oljject  is 
to  determine  the  absence  or  presence  of  this  variety  of  albumen 
in  the  urine.  Albumen  is  sometimes  associated  with  globulin  in 
certain  forms  of  advanced  Bright's  disease.  Globulin  is  a  con- 
gener of  albumen,  and  coexists  with  it  in  the  serum  of  the 
blood.  Its  presence  in  quantity  in  the  urine  is  detected  by  sim- 
ply diluting  the  urine  with  a  large  amount  of  water — if  globulin 
iDe  present,  the  urine  thereupon  becomes  more  or  less  milky 
in  appearance.  This  globulin  reaction  depends  on  the  fact  that 
globulin  is  insoluble  in  pure  water,  but  is  soluble  in  saline 
solutions;  and  when  urine  containing  it  is  largely  diluted  with 
water,  the  salts  which  keep  this  substance  in  solution  are  reduced 
to  so  attenuated  a  proportion  that  they  no  longer  suffice  for  this 
purpose,  and  the  globulin  is  thrown  out  of  solution.  An  albu- 
minous urine,  which  becomes  milky  on  dilution  with  water,  has 
its  transparency  instantly  restored  by  the  addition  of  a  few 
drops  of  liquor  potassse  or  of  a  mineral  acid.  In  all  other 
respects  globulin  answers  to  the  same  tests  as  albumen,  and  its 
presence  in  the  urine  does  not  interfere  with  the  ordinary 
processes  for  albumen  testing.^ 

In  addition  to  albumen  and  globulin,  the  presence  of  which,  in  quan- 
tities appreciable  by  direct  testing,  must  always  be  regarded  as  abnormal, 
the  urine  also  contains,  both  in  health  and  in  disease,  not  unfrequently, 
certain  other  albuminoid  substances  of  which  it  is  necessary  to  take 
cognizance.  These  are  peptone,  heniialbtanose,  mucin,  and  the  coloring- 
matters  of  the  blood — hcemoglobin  and  viefhcemoglobin. 

Peptone  and  Hemialbvmose. —  Minute  quantities  of  peptone  appear 
occasionally  in  the  urine  of  healthy  persons,  and  cannot  be  said  to  have 

1  I  sometimes  think  it  possible  that  the  parasite  is  of  exotic  origin,  and  that  the 
patient  brought  it  home  with  him  from  South  America  or  India.  If  so,  simihir 
cases  must  be  loolied  for,  not  in  Europe,  but  in  tropical  regions. 

2  Globulin  may  more  accurately  be  detected  by  saturating  the  urine  with  sul-. 
phate  of  magnesia,  which  precipitates  globulin  from  its 'solutions. 


186  ABNOEMAL    SUBSTANCES    IN    THE    URINE. 

any  pathological  significance.  Hemialbumose  seems  to  be  very  rarely 
present  in  the  urine.  It  was  discovered  in  a  case  of  osteomalacia  by 
Dr.  Bence  Jones/  and  named  by  him  hydrated  deutoxide  of  albumen. 
It  was  subsequently  found  by  Kiihue  in  a  similar  case,  and  named  hemi- 
albumose. Its  chemical  reactions  ar,e  still  imperfectly  understood.  It 
is  precipitated  by  nitric  acid  in  the  cold,  but  the  precipitate  is  redis- 
solved  with  excess  of  the  acid  on  heating.  It  is  not  precipitated  by 
boiling.  Picric  acid  throws  it  down.  It  is  considered  as  identical  with 
the  pro-pepton  of  Schmidt-Miilheim  and  with  the  a-pepton  of  Meissner, 
and  is  one  of  the  transitional  phases  in  the  peptic  and  tryptic  digestion 
of  albumen.^  Peptone  in  minute  quantities  seems  to  be  often  present 
in  the  urine — and  occasionally  in  large  quantities,  constituting  a  con- 
dition which  has  been  named  "peptonuria" — about  which,  however, 
very  little  is  known.  Peptone  is  thrown  down  by  picric  acid,  and  by 
acidulated  solution  of  common  salt,  but  is  not  precipitated  by  nitric 
acid  nor  by  boiling. 

Mucin. — Traces  of  mucin  in  a  state  of  solution  seem  to  be  present  in 
all  urines,  both  healthy  and  morbid ;  but  not  unfrequently  mucin  is 
present  in  considerable  quantities  in  the  urine  of  patients  suffering  from 
ail  kinds  both  of  grave  and  trivial  disorders.  Further  researches  are 
required  to  indicate  its  real  clinical  significance.  In  searching  for 
minute  traces  of  albumen  in  the  urine,  the  presence  of  mucin  occasions 
more  frequent  embarrassment  than  any  other  substance.  Mucin  is  pre- 
cipitated by  the  organic  acids  ;  and  the  precipitate  is  not  redissolved  by 
the  addition  of  these  acids  in  excess,  nor  by  boiling.  It  is  not  thrown 
down  by  the  strong  mineral  acids,  but  when  these  are  largely  diluted, 
they  produce  the  same  effect  as  the  organic  acids.  The  best  way  of  de- 
tecting mucin  is  by  means  of  a  saturated  solution  of  citric  acid.  If  such 
a  solution  be  added  to  urine  in  a  test-tube,  in  the  same  way  as  in  the 
contact  method  of  applying  the  nitric  acid  test  for  albumen — that  is  to 
say,  if  it  be  allowed  to  trickle  along  the  sides  of  the  tube  until  it  forms 
a  distinct  layer  below  the  column  of  urine — there  will  gradually  appear, 
if  mucin  be  present,  an  opalescent  zone  immediately  above  the  layer  of 
acid.  Acetic  and  lactic  acids  are  less  appropriate  for  eliciting  the  mucin 
reaction  than  the  strong  citric  acid  solution,  because,  owing  to  their  less 
specific  gravity,  they  do  not  so  readily  sink  to  the  bottom  of  the  tube, 
and  form  a  distinct  layer  below  the  urine.  But  if  acetie  acid  be  mixed 
with  one-third  of  its  bulk  of  glycerine,  it  acquires  the  dure  density,  and 
answers  perfectly  as  a  mucin  test.  Sometimes  mucin  is  so  abundantly 
present  that  the  free  addition  of  acetic  acid,  without  any  precautions, 
produces  a  marked  milkiness  in  the  urine. 

Hcemoglobin  and  Meihczmoglohin. — These  bodies  constitute  the  coloring- 
matters  of  the  blood,  and  their  presence  in  urine  is  recognized  by  the 
blood-color  which  they  impart  to  the  secretion.     (See  Hsemoglobinuria.) 

Qualitative  Testing  eor  Albumen. — The  best  tests  for  albu- 
men are  coagulation  by  boiling,  and  nitric  acid;  in  doubtful 
cases  the  two  tests  should  be  used  in  succession. 

1  Bence  Jones,  Animal  Chemistry,  p.  109. 

2  See  Salkowski,  Die  Lehre  vom  Harn.,  p.  210 ;  also  Dr.  Gowers's  case,  Lancet, 
1878,  ii.  p.  3. 


ALBUMEN     IN    THE     U  K I  N  K  .  187 

Boilwg. — Tl'ii  urine  possosKinii;  itH  ukuuI  acid  roactioti  bo  boiled 
in  a  test-tube,  it  beconien  tui'l)id  ifit  contain  albumen;  and  thiH 
turbidity  is  not  removed  by  the  addition  of  an  acid.  VVb(;n  the 
urine  is  turbid  from  deposition  of  amorphous  urates,  ItoiJirif^ 
alone  is  a  complete — and  the  best — test  for  albumen.  The 
deposition  of  the  urates  is  sufficient  evidence  that  the  urine  is 
frankly  acid;  when  such  a  urine  is  heated,  the  urates  are  speedily 
dissolved  and  the  urine  becomes  transparent,  but  as  the  tem- 
perature approaches  the  boiling  point  the  urine  again  becomes 
turbid  if  it  contain  albumen. 

In  using  the  boiling  test  it  is  of  the  first  importance  to  attend 
to  the  due  acidulation  of  the  urine.  For  if  the  urine  be  alkaline 
an}^  albumen  it  may  contain  is  not  coagulated  on  boiling. 
Again,  if  the  urine  be  alkaline,  or  neutral,  or  oidy  slightly  acid, 
it  "may  become  turbid  on  boiling,  from  precipitation  of  the 
earthy  phosphates.  Turbidity  from  this  cause  is  distinguished 
from  that  produced  by  albumen  by  the  addition  of  a  drop  or  two 
of  acetic  or  nitric  acid.  This  immediately  dissolves  a  phosphatic 
precipitate,  but  has  no  effect  on  albumen. 

To  avoid  these  sources  of  fallacy,  the  best  way  is  to  acidulate 
the  urine  before  boiling  with  acetic  acid.  Care  must,  however, 
be  taken  not  to  add  too  much  nor  too  little  acid,  otherwise  the 
delicacy  of  the  test  is  much  impaired.  The  following  procedure 
may  be  relied  on  to  yield  trustworthy  results.  A  test-tube  is 
charged  with  about  three  fluid-drachms  (10  c.c.)  of  urine.  To 
this  is  added  a  single  drop  of  acetic  acid.  The  upper  half  of 
the  column  is  then  heated  to  ebullition.  If  albumen  be  present, 
the  upper  boiled  portion  of  the  column  will  show  opalescence, 
in  contrast  with  the  lower  half,  Avhich  remains  unchanged.  If 
the  urine  be  alkaline,  it  should  be  carefully  neutralized  by  add- 
ing successive  drops  of  acetic  acid,  until  the  litmus  paper  shows 
a  distinct,  but  slight,  acidity,  and  then  the  iinal  single  drop  of 
acid  is  added  before  boiling.  Even  if  the  urine  possesses  its 
natural  acidity  it  is  better  to  add  a  drop  of  acid  if  3"0U  want  to 
bring  out  the  maximum  sensitiveness  of  the  boiling  test.  When 
performed  with  these  precautions  the  boiling  test  is  the  most 
sensitive  and  the  most  reliable  of  all  albumen  tests. 

Nitric  Acid. — Nitric  acid  is  an  extremely  delicate  test  for 
albumen ;  and  it  is  the  first  test  to  use  in  all  cases  except  when 
the  urine  is  turbid  from  urates.  The  best  manner  of  applying 
it  is  to  fill  a  test-tube  to  the  depth  of  about  an  inch;  then,  in- 
clining the  tube,  to  pour  in  strong  nitric  acid  in  such  a  manner 
that  it  may  trickle  down  along  the  side  of  the  tube  to  the  bot- 
tom, and  form  a  stratum  some  quarter  of  an  inch  thick  below 
the  urine.  Added  in  this  manner  there  is  scarcely  an}-  mingling 
of  the  two  fluids,  and  if  albumen  be  present,  three  strata  or 
layers  will  be  observed:  one,  perfectly  colorless,  of  nitric  acid' 


188  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

at  the  bottom ;  immediately  above  this  an  opalescent  zone  of 
coagulated  albumen;  and  atop  the  unaltered  urine.  If  there  be 
only  a  trace  of  albumen,  twenty  or  thirty  minutes  elapse  before 
the  opalescent  zone  becomes  visible. 

This  mode  of  testing  for  albumen,  whereby  the  reagent  is  so  intro- 
duced that  it  forms  a  distinct  and  separate  layer  either  above  or  below 
the  urine,  has  been  conveniently  termed  by  Dr.  Oliver  the  contact 
method, 

Mtric  acid  applied  by  the  contact  method  is  the  simplest  and 
least  troublesome  means  of  detecting  albumen  in  the  urine.  The 
reaction  of  the  urine  does  not  interfere  with  its  operation.  Only 
one  caution  is  necessary.  In  concentrated  urines,  and  especially 
febrile  urines,  the  addition  of  the  acid  is  apt  to  precipitate  the 
amorphous  urates,  and  thus  to  occasion  a  turbidity  which  might 
be  mistaken  for  albumen.  The  two  conditions  are  however 
easily  distinguished  by  observing  the  level  at  which  the  cloudi- 
ness begins,  and  the  direction  in  which  it  spreads.  Albumen 
begins  to  coagulate  immediately  above  the  stratum  of  acid,  and 
the  turbidity  spreads  upwards;  but  the  urates  first  appear  at  or 
near  the  surface  of  the  urine,  and  the  opacity  spreads  down- 
wards. Heat  also  readily  resolves  the  doubt;  for  the  urates 
speedily  disappear  when  the  urine  is  warmed,  but  turbidity  from 
albumen  is  not  affected  by  heat. 

The  urine  of  patients  who  are  taking  cubebs  and  copaiba  is 
commonly  somewhat  opalescent,  and  nitric  acid,  in  the  cold, 
sometimes  (not  always)  increases  the  opalescence.  The  sense 
of  smell  immediately  directs  attention  to  the  presence  of  these 
drugs,  and  heat  diminishes  the  opalescence  and  prevents  any 
turbidity  with  nitric  acid. 

In  urines  which  are  over- rich  in  urea,  nitric  acid,  in  the 
cold,  causes  a  slow  precipitation  of  a  crystalline  mass  of 
nitrate  of  urea,  which,  however,  is  so  different  in  appearance 
from  coagulated  albumen  that  it  can  scarcely  be  mistaken 
for  it. 

It  is  further  to  be  remarked,  that  if  the  manner  above  de- 
scribed of  testing  for  albumen  with  nitric  acid  be  not  followed, 
two  notable  fallacies  may  be  encountered.  On  the  one  hand  (as 
was  pointed  out  by  Bence  Jones),  if  the.  urine  be  acidified  with 
a  small  quantity,  a  drop  or  so,  of  nitric  acid,  the  albumen  may 
not  be  coagulated  at  all;  and  on  the  other  hand,  if  a  large 
quantity  of  acid  (an  equal  volume)  be  suddenly  added  to,  and 
mixed  with  the  urine,  the  mixture  remains  perfectly  clear,  even 
though  it  be  highly  albuminous. 

Other  Tests  for  Albumen. — Several  other  substances,  besides  heat  and 
nitric  acid,  precipitate  albumen  ;  namely,  alcohol,  tannin,  carbolic  acid, 


ALBUMEN    IN    THE    URINE.  189 

chromic  acid,  acidulated  brine/  metaphosphoric  acid,'"'  ferrocyanide  of 
potassium,'  saturated  solution  of  i)icric  acid,'  tungstate  of  soda,''  potassio- 
mercuric  iodide,"  and  certain  other  metallic  salts.  »Sotne  of  these  have 
been  recently  strongly  reconiniended  as  tests  foi'  albumen  in  the  urine; 
and  it  has  been  claimed  on  their  behalf  that  they  are  superior  in  deli- 
cacy to  heat  and  nitric  acid. 

Those  which  have  attracted  the  most  attention,  and  which  I  have 
especially  subjected  to  examination,  are  acidulated  brine,  tungstate  of 
soda,  mercuric  iodide,  and  ferrocyanide  of  j)otassium.  The  common 
defect  of  these  tests  is  that  they  not  unfrequently  give  a  reaction  with 
normal  urines,  or  with  morbid  urines,  which  do  not  contain  serum- 
albumen.  I  believe  that  the  most  frequent  source  of  fallacy  in  their  use 
is  not  peptone  nor  hemialbumose,  but  mucin.  They  all  throw  down 
mucin  in  a  manner  indistinguishable  (without  further  testing)  from 
albumen.  When  the  contact  method  is  followed,  they  yield,  if  the  urine 
contain  mucin,  an  opalescent  zone  at  the  junction  of  the  two  fluids,  and 
they  yield  exactly  the  same  reaction  if  the  urine  contain  albumen.  Now 
the  use  of  nitric  acid  avoids  this  fallacy.  The  opalescent  zone  produced 
at  the  line  of  contact  by  nitric  acid  is  albumen  (or  globulin),  and  noth- 
ing else.  If  mucin  be  present,  there  is  slowly  produced  a  haze  at  the 
middle  and  upper  parts  of  the  column  of  urine,  and  not  at  the  line  of 
contact.  Sometimes  the  mucin-haze,  with  very  careful  addition  of  the 
acid,  forms  a  fairly  distinct  ring  or  zone  about  midway  between  the  con- 
tact line  and  the  top  of  the  column  of  urine ;  and  now  and  then  a  urine 
is  encountered  in  which  a  double  zone  is  witnessed,  one  consisting  of 
albumen  immediately  above  the  line  of  junction  of  the  two  fluids,  and 
another  higher  up  composed  of  mucin.     This  behavior  of  mucin  w-ith 

1  Proposed  by  myself.  This  test  is  composed  of  a  saturated  solution  of  common 
salt  acidulated  with  one  per  cent,  of  strong  hydrochloric  acid.  See  a  paper  by  the 
author  in  The  Lancet,  1882,  ii.  p.  823. 

2  Metaphosphoric  acid  is  a  veiy  sensitive  test  for  albumen — but  its  solutions 
change  slowly  into  orthophosphoric  acid  and  then  cease  to  coagulate  albumen. 
This  is  a  fatal  objection  to  its  clinical  use. 

^  Suggested  by  Dr.  Pavy.  The  objection  to  this  test  is  that  it  throws  down 
mucin  owing  to  the  strong  acidulation  with  acetic  acid  which  is  required  to  bring 
out  its  action. 

*  First  proposed  by  Galippe,  and  recently  strongly  advocated  by  Dr.  George 
Johnson  (The  Lancet,  1882,  li.  p.  737,  and  Albumen  and  Sugar  Testing,  Lond. 
1884).  Applied  by  the  contact  method  this  is  a  very  delicate  test  for  albnmcn^- 
but  inasmuch  as  it  throws  down  mucin  and  peptone  in  a  manner  quite  indistin- 
guishable from  albumen  (except  by  further  control  testing — by  heat  or  nitric  acid), 
its  use  involves  additional  time  and  trouble.  Picric  acid  also  gives  a  precipitate  in 
the  urine  of  persons  taking  large  duses  of  quinine. 

^  This  test  was  introduced  by  Dr.  Oliver  (On  Bedside  Urine  Testing,  Lond..  1883). 
It  is  prepared  by  mixing  together  equal  parts  of  the  saturated  solutions  of  tung- 
state of  soda  (one  in  four),  and  of  citric  acid  (ten  in  six),  and  of  water.  It  is  ap- 
plied by  the  contact  method  and  is  of  extreme  delicacy — but  it  is  fatally  viiiat:d 
as  a  clinical  test  b}^  the  fact  that  it  gives  a  reaction  more  or  less  pronounced  with 
most  urines  both  healthy  and  morbid. 

^  Proposed  by  Ch.  Tanret  of  Paris.  It  is  composed  of  2.70  parts  of  bichloride 
of  mercury  and  6.64  parts  of  iodide  of  potassium  dissolved  in  lOO  pans  of  water. 
In  applying  this  test  the  urine  requires  to  be  strongly  acidulated  with  acetic  or 
citric  acid.  This  test  is  of  the  most  extreme  sensitiveness,  but  it  is  wholly  un- 
suitable for  urine  testing  for  the  same  reason  as  the  foregoing,  namely,  that  it 
gives  a  slight  reaction  with  nearl}'  all  urines. 


190  ABNORMAL    SUBSTANCES    IN    THE    URINE, 

nitric  acid  is  easily  understood  when  it  is  remembered  that  while  mucin 
is  not  thrown  down  by  strong  nitric  acid,  it  is  thrown  down  by  that  acid 
in  a  highly  diluted  state. 

In  regard  to  highly  or  even  very  moderately  albuminous  urines,  all 
these  tests  give  an  unmistakable  reaction  ;  but  when  we  are  in  search  of 
minute  traces  of  albumen  they  fail  us,  simply  because  their  reactions  do 
not  distinguish  between  the  presence  of  albumen  and  the  presence  of 
other  proteids  which  have  either  no  morbid  significance  or  have  a 
significance  wholly  different  from  that  of  albumen.  It  is  for  this 
reason  that  I  have  been  constrained  to  abandon  the  use  of  acidulated 
brine.  I  found  it  so  often  necessary,  when  minute  traces  of  albumen 
were  in  question,  to  control  the  indications  with  heat  and  nitric  acid, 
that  it  became  evident  that  it  cost  less  time  and  trouble  to  resort  at  once 
to  the  more  reliable  tests. 

It  is,  no  doubt,  desirable  that  we  should  possess  a  test  for  albumen 
somewhat  more  sensitive  than  nitric  acid  ;  but  it  is  a  condition,  sine  qua 
non,  that  such  a  test  shall  be  equally  reliable,  and  this  condition  is  not 
fulfilled  by  any  of  the  tests  hitherto  introduced.  They  all,  without  ex- 
ception, give  a  reaction  with  something  that  is  not  serum-albumen,  and 
are,  therefore,  untrustworthy,  and  apt  to  lead  to  serious  misapprehension. 
The  following  table  brings  into  strong  light  the  necessity  of  abiding  by 
the  old  tests.  It  gives  the  results  of  the  examination  of  the  urine  of 
thirty-one  perfectly  healthy  men,  most  of  them  students  and  candidates 
for  insurance.  None  of  these  urines  gave  the  slightest  reaction  by  care- 
ful testing  with  heat  and  nitric  acid  : 

Reaction.      No  reaction. 
Heat 0  31 


Nitric  acid  . 
Acidulated  brine 
Picric  acid . 
Tungstate  test     . 
Mercuric  iodide  . 


0  31 

11  20 

14  17 

28  3 

26  5 


It  may  be  objected  that  the  failure  of  heat  and  nitric  acid  to  give  a 
reaction  with  these  urines  arose  from  a  want  of  sufiicient  delicacy;  but 
this  was  not  really  the  cage.  I  have  shown  elsewhere  ^  that  the  boiling 
test,  when  attention  is  paid  to  the  due  acidulation  of  the  urine,  is  supe- 
rior in  sensitiveness  to  any  of  the  new  tests. 

The  Quantitative  Estimation  of  albumen  in  urine  is  a 
matter  of  considerable  practical  importance,  and  various  plans 
of  attaining  this  object  have  been  devised. 

For  precise  determinations  the  plan  usually  followed  is  to 
bring  a  measured  quantity  of  urine  to  a  slightly  acid  condition  ; 
boil;  throw  on  a  weighed  filter;  wash;  dry  at  212°;  and  weigh. 
This  proceeding  demands  a  good  deal  of  time.  The  filtering  is 
sometimes  impossible;  and  the  results  obtained  are  only  mod- 
erately accurate  with  every  care. 

1  Glasgow  Medical  Journal,  1884. 


ALBUMEN     IN    THE     UJUNE.  191 

For  a  rough-and-ready,  but  useful,  method,  there  is  none 
superior  to  boiling  the  urine  in  a  test-tube  with  a  drop  or  two 
of  acetic  acid.  The  albumen  coagulates  in  flaices,  and  presently 
sinks  to  the  bottom,  forming  a  layer  of  various  thickness.  The 
proportion  of  albumen  is  judged  of  by  the  depth  of  this  layer 
as  compared  to  the  height  of  the  column  of  urine  in  the  tube. 
This  proportion  may  be  expressed  in  numbers,  as  ^,  j-,  -^  ,  and 
so  forth.  If  the  quantity  of  albumen  be  too  small  to  form  a 
layer  of  appreciable  depth,  the  proportion  is  expressed  more 
loosely,  as  a  "cloudiness"  or  an  "opalescence."  The  varying 
density  of  albuminous  urines,  and  the  varying  size  of  the  flakes 
into  which  albumen  coagulates,  affect  the  rapidity  and  com- 
pleteness of  the  subsidence  and  therefore  the  depth  of  the  coagu- 
lated layer,  so  that  only  approximate  results  can  be  expected 
from  this  method. 

Becquerel  ingeniously  turned  to  account  the  property  of 
albumen  to  deviate  the  plane  of  polarization  to  the  left;  and 
constructed  an  instrument  on  a  similar  plan  to  the  optical  sac- 
charimeter,  by  which  the  deviation  could  be  measured,  and  the 
percentage  of  albumen  calculated  therefrom.  It  would  appear, 
however,  that  this  instrument,  on  Becquerel's  own  showing,  is 
only  capable  of  very  limited  clinical  application.  When  the 
quantity  of  albumen  is  considerable  it  gives  very  exact  indica- 
tions ;  but  the  deviation  is  too  slight  for  exact  estimation  in 
moderately  and  feebly  albuminous  urines;  it  is  therefore  useless 
for  the  bulk  of  albuminous  urines.' 

Boedecker  has  proposed  a  volumetrical  method,  founded  on 
the  property  of  ferrocyauide  of  potassium  to  form  an  insoluble 
compound  of  fixed  composition  with  albumen.  Yogel  states 
that  he  has  found  this  method  inaccurate.^ 

Minimetric  Method  or  Dilution  Method. — In  1876  I  proposed  a 
mode  of  estimating  albumen  in  urine,  which  I  think  may  prove 
useful  in  clinical  work.^  The  principle  of  the  method  is  easily 
understood. 

When  an  albuminous  urine  is  progressively  diluted  with 
water,  and  tested  from  time  to  time  with  nitric  acid,  the  opacity 
induced  b}'  the  test  becomes  gradually  fainter  and  fainter,  until 
at  length  it  ceases  to  be  visible.  This  point  is  reached  when 
the  urine  contains  less  than  about  0.0014  per  cent,  of  albumen. 
The  more  albumen  the  urine  contains,  the  more  dilution,  of 
course,  it  will  require  to  reach  the  vanishing  point  of  the  reac- 
tion ;  and  if  we  could  fix  this  point  with  accuracy,  we  should 

1  See  a  clinical  lecture  by  Becquerel,  Clinique  Europeene,  1859. 

2  Boedecker's  method  is  described  in  Henle  and  Pfeufer's  Zeitsch.,  1859,  p.  321. 
^  For  a  fuller  account  of  this  method  the  reader  is  referred  to  a  paper,  by  the 

iiuthor,  read  before  the  Medico-Chirurgical  Society,  Feb.  22,  1876. 


192  ABNORMAL    SUBSTANCES    IN    THE    URINE, 

have  a  simple  method  of  estimating  albumen  in  urine.  The 
urine  could  be  diluted  until  it  ceased  to  react  with  nitric  acid, 
and  the  amount  of  dilution  required  to  reach  this  point  would 
furnish  a  measure  of  the  proportion  of  albumen. 

But  it  is  not  possible  to  fix  this  point  with  accuracy.  The 
opacity  produced  by  the  acid  fades  away  so  gradually  with 
increasing  additions  of  water,  that  it  is  impracticable  to  decide 
within  many  degrees  the  point  at  which  the  reaction  ceases  to  be 
appreciable.  And  not  only  so,  but  the  development  of  the  re- 
action becomes  more  and  more  retarded  as  the  dilution  proceeds, 
until  at  length  it  only  becomes  visible  after  the  lapse  of  several 
minutes. 

To  overcome  this  difficulty,  it  was  found  necessary  to  fix  on 
some  arbitrary  point  or  line  which  would  serve  as  a  practicable 
zero  to  the  scale.  After  many  trials,  it  was  found  most  con- 
venient to  draw  the  line  at  a  reaction  coming  into  sight  midway 
between  half  and  three-quarters  of  a  minute  after  the  contact  of 
the  acid — that  is,  to  dilute  the  urine  until  it  gives  no  reaction 
for  thirty  seconds  after  the  addition  of  the  acid,  but  shows  a 
distinct  opalescence  at  the  forty-fifth  second.  The  exact  point  to 
be  aimed  at  is  a  reaction  coming  doubtfully  into  view  between 
the  thirty-fifth  and  fortieth  second,  and  appearing  still  very  dim, 
but  unmistakable  at  the  forty-fifth  second.  It  was  found  pos- 
sible, after  a  little  practice,  to  strike  this  point  with  sufficient 
exactness  to  serve  as  a  practicable  zero  to  the  scale. 

Each  dilution  with  an  equal  volume  is  counted  as  one  degree 
on  the  scale,  and  these  degrees  may  be  conveniently  termed 
"  degrees  of  albumen."  Thus,  a  urine  requiring  dilution  with 
forty  times  its  bulk  of  water  to  reach  the  zero  reaction,  may 
be  described  as  possessing  forty  degrees  of  albumen^a  urine 
requiring  three  hundred  similar  dilutions  as  possessing  300 
degrees  of  albumen,  and  so  forth. 

The  difficulty  of  the  method  is  to  hit  correctly  the  zero  re- 
action. When  this  point  is  approached,  a  little  more  or  a  little 
less  dilution  makes  but  a  slight  difference  in  the  time  at  which 
the  reaction  appears.  In  order  therefore  to  obtain  exact  results, 
it  is  necessary  to  conduct  the  testing  with  rigid  uniformity.  The 
test-tube  employed  should  have  an  interior  diameter  of  f  of  an 
inch  (15  millimetres);  the  acid  must  be  added  in  the  right  way, 
and  at  the  right  moment.  The  operation,  too,  should  be  per- 
formed by  daylight,  or,  if  by  gaslight,  an  addition  of  about  five 
per  cent,  must  be  made  to  the  results.  The  proceeding  adopted 
is  as  follows :  The  urine  is  first  tested  in  the  usual  way  with 
nitric  acid,  so  as  to  get  a  rough  idea  of  the  quantity  of  albumen 
contained  in  it,  and  of  the  degree  of  dilution  likely  to  be  re- 
quired to  reach  the  zero.  The  watch  is  placed  on  the  table 
before  the  operator.     A  fluid-drachm  of  the  urine  is  then  meas- 


ALJ5UMEN    IN    'JMIE    UKINE.  1.93 

ured  off",  and  iiiti-oducod  into  a  graduated  pint  rricaHuro,  and 
water  is  added  up  to  a  few  or  many  ounces,  according  to  tlie 
degree  of  dilution  likely  to  be  required  to  approach  the  zero 
reaction.  The  test-tube  is  then  filled  to  the  depth  of  about  an 
inch  with  the  diluted  urine  and  held  widely  inclined  from  the  per- 
pendicular. The  eye  is  now  directed  to  tlie  watch,  and  the  acid 
is  added  in  such  a  manner  that  it  runs  along  the  lower  side  of 
the  tube  to  tlie  bottom  and  forms  a  distinct  layer,  about  a  quarter 
of  an  inch  deep,  below  the  diluted  urine.  The  acid  must  be 
added  exactly  on  one  of  the  quarter-minute  strokes.  This  is 
the  most  critical  step  in  the  proceeding,  and  it  should  be  per- 
formed in  the  following  manner:  A  pointed  glass  tube  or 
pipette  is  dipped  to  the  depth  of  a  couple  of  inches  into  the 
acid  and  covered  with  the  forefinger.  The  pipette  thus  guarded 
is  then  passed  into  the  test-tube  to  within  half  an  inch  of  the 
level  of  the  diluted  urine,  and  at  the  right  moment  the  finger  is 
removed  and  the  charge  of  acid  delivered.  As  soon  as  the  acid 
is  added,  the  test-tube  is  held  up  to  the  light  against  some  dark 
background  (such  as  a  black  sleeve,  a  book  bound  in  black 
cloth,  or  a  dark  corner  of  the  room),  and  as  soon  as  the  faintest 
opalescence  is  perceived  above  the  level  of  the  acid,  the  time  of 
its  appearing  is  noted.  If  this  appear  at  or  before  thirty  sec- 
onds after  the  contact  of  the  acid,  more  water  is  added,  and  the 
testing  repeated  as  before.  Thus,  by  successive  additions  of 
water,  and  repeated  testings,  a  close  approximation  to  the  zero 
reaction  is  obtained.  A  fresh  dilution  is  then  prepared,  and, 
guided  by  the  previous  trials,  two  or  three  testings  with  different 
dilutions  are  generally  sufficient  to  indicate  with  exactness  the 
dilution  which  produces  an  opalescence  between  the  thirty-fifth 
and  forty-fifth  second  after  the  addition  of  the  acid. 

If  too  much  water  is  added  in  the  first  instance,  the  reaction 
does  not  appear  till  after  the  forty-fifth  second.  In  this  case  the 
operation  must  be  recommenced  with  less  water,  and  proceeded 
with  as  in  the  first  case. 

When  the  zero  reaction  is  determined,  the  degree  of  dilution 
required  to  produce  it  is  noted,  and  expressed  in  multiples  of 
the  unit-volume  of  urine  employed.  Thus,  if  a  fluid-drachm 
was  the  unit-volume  of  urine  employed,  and  the  zero  reaction 
was  obtained  when  dilution  was  carried  up  to  fifteen  ounces 
(120  drachms),  the  urine  is  recorded  as  having  120  degrees  Of 
albumen. 

If  the  urine  is  feebly  albuminous — indicating  less  than  20 
degrees  of  albumen — the  fluid-ounce  should  be  substituted  for 
the  fluid-drachm  as  the  unit-volume.  On  the  other  hand,  if  the 
urine  indicate  more  than  160  degrees  of  albumen,  the  unit- 
volume  should  be  half  a  drachm — or,  still  better,  the  urine 
should  be  previously  diluted  with  water  in  the  proportion  of  1 

13 


194  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

in  2  or  1  in  4,  and  the  result  afterwards  multiplied  by  2  or  4  as 
the  case  may  be. 

The  actual  value  in  weight  of  albumen  of  each  degree  on  the 
dilution  scale  was  found,  by  careful  comparative  experiments 
with  the  weighing  method,  to  correspond  to  0.0034  per  cent., 
or  0.0148  grain  per  fluid-ounce  of  the  British  Pharmacopoeia. 
These  data  supply  an  easy  means  of  calculating  the  quantity  of 
albumen  per  ounce,  and  also  the  daily  loss  of  albumen.  Suppose 
that  40  ounces  of  urine  were  voided  in  the  twenty- four  hours, 
and  that  a  sample  of  this  urine  showed  150  degrees  of  albumen 
by  the  dilution  method,  then  : 

0.0148X150=2.22  and  2.22x40=88.8. 

The  urine  contained  2  22  grains  of  albumen  per  ounce,  and  the 
daily  loss  was  88.8  grains. 

The  time  required  for  the  estimation  of  albumen  in  urine  by 
this  method  is  from  ten  to  twenty  minutes. 

Clinical  Significance  of  Albumen  in  the  Urine. — In  con- 
sidering this  subject  all  those  cases  are,  of  course,  excluded  in 
which  the  occurrence  of  albumen  is  only  incidental  to  the  pres- 
ence of  some  other  fluid  in  the  urine,  such  as  blood  or  pus. 

The  pathological  states  in  which  albumen  appears  constantly 
or  occasionally  in  the  urine  may  be  arranged  in  the  following 
groups : 

1.  Acute  and  chronic  Bright's  disease  of  the  kidneys. 

2.  Pregnancy  and  the  puerperal  state. 

3.  Febrile  and  inflammatory  diseases  (zymotic  diseases,  such 
as  scarlet  fever,  measles,  smallpox,  typhoid,  cholera,  yellow 
fever,  ague,  diphtheria,  etc.;  inflammatory  diseases,  such  as 
pneumonia,  peritonitis,  traumatic  fever,  acute  articular  rheuma- 
tism, etc.). 

4.  Impediments  to  the  circulation  of  the  blood  (emphysema, 
heart  disease,  abdominal  tumors,  cirrhosis,  etc.). 

5.  A  hydrsemic  and  dissolved  state  of  the  blood  and  atony  of 
the  tissues  (purpura,  scurvy,  pj^-semia,  hospital  gangrene) ;  also 
hfemoglobinnria. 

6.  Saturnine  intoxication. 

7.  Functional  disorders  (albuminuria  of  adolescents,  physio- 
logical albuminuria). 

8.  Nervous  disturbance  (neurotic  albuminuria). 

In  the  first  group  albuminuria  is  dependent  on  structural 
changes  in  the  kidneys  {see  Bright's  Disease). 

In  the  second  group  albuminuria  is  sometimes  associated  with 
structural  changes,  and  sometimes  not  {see  Connection  of  Bright's 
Disease  and  Pregnancy). 

In  all  febrile  and  inflammatory  complaints  a  trace  of  albumen 
is  frequently  found  in  the  urine ;  it  usually  amounts  to  no  more 


ALBUMEN     IN    THE     URINE.  195 

than  a  trace,  and  disappoars  on  dofervosccnce ;  HonietinicH  in 
pneumonia  it  is  not  inconsiderable.  As  intercurrent  febrile 
attacks  are  common  in  the  course  of  most  chronic  complaints, 
temporary  albuminuria  has  been  noted  in  a  great  multitude  of 
different  diseases.  This  remark  applies  especially  to  chronic 
tuberculosis,  cancer,  caries,  and  necrosis ;  and  albuminuria  under 
such  a  condition  is  to  be  carefully  distinguished  from  the  cases 
in  which  genuine  Briglit's  disease  coexists  with  those  complaints. 
In  a  zymotic  disease  there  is  a  double  pathological  state,  namely, 
pyrexia  and  the  operation  of  a  specific  poison;  and  albumen 
may  appear  in  the  urine  either  as  an  incident  of  the  febrile  state, 
when  it  is  comparatively  unimportant,  or  as  an  indication  of 
serious  structural  changes  in  the  kidneys,  which  constitute  a 
grave  sequela  of  the  disease. 

Albuminuria  connected  with  impediments  to  the  circulation 
of  the  blood  is  considered  under  Congestion  of  the  Kidney. 

In  a  dissolved  or  putrid  state  of  the  blood,  albumen  appears 
in  the  urine  without  being  connected  with  organic  changes  in 
the  kidney;  it  is  associated  with  the  escape  of  the  coloring 
matter  of  the  blood  {see  Hsemoglobinuria). 

Saturnine  Albuminuria. — The  occurrence  of  albumen  in  the 
urine  of  persons  poisoned  with  lead,  although  repeatedly  ob- 
served, was  not  regarded  as  anything  more  than  a  coincidence 
until  Ollivier  demonstrated,  by  experiments  on  animals  and 
clinical  observations,  the  existence  of  a  causal  connection  between 
them.  Ollivier^  found  that  dogs,  rabbits,  and  guinea-pigs,  when 
poisoned  with  repeated  doses  of  carbonate  of  lead,  invariably 
passed  an  albuminous  urine,  and  that  their  kidneys  exhibited 
signs  of  incipient  organic  disease.  He  also  collected  15  ex- 
amples of  albuminuria  in  persons  poisoned  with  lead.  Seven 
of  these  had  temporarj^  albuminuria;  in  three,  the  albuminuria 
persisted  during  the  continuance  of  the  saturnine  symptoms ; 
and  in  four,  genuine  Bright's  disease  had  been  produced.  In 
addition  to  these  observations,  he  examined  the  urine  of  37 
persons  affected  with  diverse  manifestations  of  lead-poisoning  in 
the  Hopital  de  la  Charite :  of  these,  nine  had  albuminous  urine. 
These  observations  have  been  conlirmed  by  Lancereaux^  and 
Danjoy.^  Ollivier  found  that  both  the  urine  and  the  kidneys  in 
those  cases  contained  traces  of  lead.  He  inferred  that  the 
existence  of  lead  in  the  kidneys  induced  an  organic  lesion  of 
these  organs,  and  that  the  albuminuria  was  the  consequence  of 
that  lesion. 

This  has  been  proved  experimentally  b}'  Charcot  and  Grom- 

1  Archives  Generales,  1863,  ii.  pp.  530  and  709. 

2  Union  Medicale,  1863,  and  Bulletins  de  la  Societe  medicale  d'Eniulation, 
nouvelle  serie,  t.  i.  p.  182,  1864. 

3  Archives  Generales,  1864,  i.  p.  402. 


196  ABNORMAL    SUBSTANCES    IN"    THE    URINE. 

bault\  who  fed  animals  on  lead  salts,  and  so  induced  nephritis. 
Numerous  observations  on  the  human  subject  have  clearly  estab- 
lished the,  relation  between  lead  poisoning  and  the  granular 
kidney  of  Bright's  disease  {sre  Dr.  Dickinson  on  "  Albuminuria," 
p.  882,  and  Wagner  on  "  Die  Bleischrurapfniere,"  in  "  Ziemssen's 
Cyclopged.,"  '6d  edition,  vol.  ix.  p.  291). 

Functional  Albuminuria. — The  excessive  use  of  a  diet  composed 
exclusively  or  chiefly  of  albuminous  matters,  such  as  eggs,  has 
been  shown  by  Barreswil,  Brown-Sequard  and  others  to  cause 
the  urine  to  become  slightly  albuminous. 

Slight  and  temporary  albuminuria  appears  to  occur  occa- 
sionally from  very  slight  disorders.  Beneke,  when  suffering 
from  dj^spepsia,  noticed  albumen  in  his  own  urme  four  times  in 
as  many  weeks.  Similar  observations  have  been  made  by  others 
(Parkes). 

The  most  important  cases,  however,  which  may  be  classed 
under  this  heading,  are  those  of  the  so-called  albuminuria  of 
adolescents,  transient,  or  physiological  albuminuria.  The  urine  of 
young  persons,  usually  at  about  the  time  of  puberty,  not  un- 
frequently  contains  a  small  amount  of  albumen,  without  any 
other  serious  symptom  showing  itself.  In  this  country  special 
attention  has  been  called  to  this  form  of  albuminuria  by  Moxon,^ 
Rooke,^  Dukes,*  and  Saundby,^  while  on  the  Continent  the 
most  important  observations  have  been  those  of  Leube^,  Edlef- 
sen,'^  Fiirbringer,^  and  Runeberg^  In  most  cases  the  subjects 
of  the  affection  show  general  want  of  tone,  lassitude  or  anaemia, 
and  often  disorders  of  digestion  may  be  noted.  But  in  many 
cases  the  general  health  is  quite  perfect.  The  amount  of 
albumen  is  usually  only  slight,  but  occasionally  may  be  con- 
siderable. It  is  a  marked  feature  of  nearly  all  such  cases,  how- 
ever, that  the  appearance  of  the  albumen  is  intermittent.  Thus, 
the  urine  passed  before  breakfast  is  usually  normal,  while 
albumen  makes  its  appearance  later  on  in  the  day.  Occasionally, 
too,  only  the  urine  passed  after  meals  contains  albumen.  An 
excess  of  uric  acid  or  of  oxalates,  and  sometimes  a  few  hyaline 
casts,  may  be  found.  Muscular  exertion  has  a  very  marked 
effect  in  inducing  this  form  of  albuminuria.  Leube  examined 
the  urine  of  119  soldiers  after  a  long  march,  and  found  albumen 
in  the  urine  of  19,  or  16  per  cent.  Dr.  Dukes  has  also  remarked 
in  schoolboys  the  effect  of  muscular  exertion  in  producing 
albuminuria ;  while  rest  in  bed,  as  shown  by  Dr.  Rooke,  fre- 
quently removes  the  condition  in  a  short  time. 

1  Archiv.  de  Physiol.,  1881,  p.  126.  ^  Guy's  Hosp,  Eeports,  xxiii.  p.  233. 

3  Brit.  Med.  Journ.,  1878,  ii.  p.  596.  ^  Idem,  1878,  ii.  p.  794. 

5  Idem,  1879,  i.  p  699.  e  Vircli.  Arch.,  72,  p.  145. 

7  Berlin.  Klin.  Wochenschr.,  Sept.  12,  1879. 

8  Zeitsch.  f.  Klin.  Medic,  1879,  i.  p.  340.         ^  Virch.  Arch.,  80,  p.  175. 


ALBUMEN    IN    THE    UKINE.  197 

Usually  the  condition  is  not  of  long  duration,  hut  exceptions 
to  tliis  rule  are  sometimes  met  with. 

The  causes  of  functional  alhuminuria  are  hy  no  means  under- 
stood, and  prohahly  may  not  he  the  same  in  all  cases.  Some 
cases  may  possihly  he  regarded  as  food-alhuminuria.  Sir  Wm, 
Gull  has  suggested  that  the  condition  is  due  to  atony  of  the 
vessels  and  nerves,  and  Bamberger  also  believes  it  due  to  vaso- 
motor change  in  the  kidney,  which  may  cause  slowing  of  the 
circulation  in  the  glomeruli.  This  appears  to  be  the  most  prob- 
able explanation  for  most  cases. 

The  prognosis  in  functional  albuminuria  is  favorable — al- 
though Dr.  G.  Johnson^  and  Dr.  Dukes  are  inclined  to  think 
that  sometimes  the  condition  may  end  in  Bright's  disease. 

The  functional  character  of  the  disorder  may  generally  be 
recognized  from  the  intermittent  occurrence  of  the  albumen, 
from  the  normal  density  and  coloration  of  the  urine,  from  the 
absence  of  other  accompaniments  of  Bright's  disease,  such  as 
high  arterial  tension  and  hypertrophy  of  the  heart,  and  from 
the  progress  of  the  case. 

Neurotic  Albuminuria. — Bernard  found  that  irritation  of  the 
renal  nerves,  or  of  a  certain  spot  in  the  floor  of  the  fourth 
ventricle  (higher  up  than  the  diabetic  puncture)  caused  albumen 
to  appear  in  the  urine  of  animals.  Temporary  or  intermittent 
albuminuria  is  sometimes  encountered  clinically  under  circum- 
stances of  disturbed  innervation,  without  structural  changes  in 
the  kidneys.  Dr.  G.  Johnson^  has  pointed  out  that  transient 
albuminuria  occasionall}-  follows  cold  bathing,  and  Dr.  La3'cock^ 
has  seen  a  similar  result  in  the  shivering  period  of  various  ague- 
like attacks.  In  vascular  bronchocele  with  exophthalmos.  Dr. 
Begbie*  has  repeatedly  observed  long-continued  intermitting 
albuminuria.  In  these  last  cases  the  albumen  appears  during 
and  after  digestion  (especially  after  breakfast),  and  disappears 
during  the  periods  of  fasting.  Some  cases  of  this  class  have  an 
evident  affinity  with  paroxj'smal  hsemoglobinuria. 

Albuminuria  is  sometimes  noticed  after  epileptic  attacks,  but 
the  records  of  the  frequency  of  its  occurrence  show  consider- 
able difterences.  In  certain  other  disturbances  of  the  nervous 
system  albuminuria  is  noticed,  as  in  cerebral  hemorrhage,  cere- 
bral concussion,  tetanus,  and  delirium  tremens.  [See  Wagner 
in  "  Ziemssen's  Cyclop.,"  3d.  edit.,  vol.  ix.  p.  27.) 

When  albumen  is  found  in  urine,  the  important  point  to 
decide  is,  whether  it  indicates  the  existence  of  organic  disease 
of  the  kidnej's  or  not.     This  question,  in  any  individual  case, 

1  Brit.  Med.  Journ.,  1879,  ii.  p.  928.  -  Ibid.,  1873,  ii.  p.  664. 

2  Dublin  Journ   of  Med.  Sci.,  July,  1874.         *  Edin.  Med.  Juurn.,  April, 1874. 


198  ABNOKMAL    SUBSTANCES    IN    THE    URINE. 

must  be  considered  chiefly  in  connection  with  the  three  follow- 
ing points  jointly,  namely: 

1.  The  temporary  or  persistent  duration  of  the  albuminuria. 

2.  The  quantity  of  the  albumen ;  and  the  occurrence  and 
character  of  a  deposit  of  renal  derivatives. 

3.  The  presence  or  absence  of  any  disease  outside  the  kidneys 
which  will  account  for  the  albuminuria. 

1.  It  has  already  been  mentioned  that  functional  albuminuria 
is  usually  only  temporary.  A  persistent  duration  of  albuminu- 
ria, on  the  other  hand,  is  very  suspicious  of  organic  disease  of 
the  kidneys.  The  importance  of  distinguishing  between  tem- 
porary and  permanent  albuminuria  was  insisted  upon  by  Dr. 
Parkes,  and  observations  relating  to  this  subject  will  be  found 
in  his  treatise  "  On  the  Composition  of  the  Urine,"  p.  186.  It 
must  be  remembered  that  in  the  granular  kidney  of  Bright's 
disease  the  albuminuria  is  often  intermittent. 

2.  The  greater  the  quantity  of  albumen,  the  more  likely  is 
the  existence  of  renal  disease;  and  a  "large"  quantity  of  albu- 
men (|-  and  upwards)  is  rarely  found,  except  in  undoubted  acute 
or  chronic  Bright's  disease.  It  is  necessary,  however,  in  con- 
sidering the  amount  of  albumen,  not  only  to  have  regard  to  the 
proportion  in  a  particular  specimen  examined,  but  also  to  the 
total  quantity  in  the  twenty-four  hours.  This  may  be  surmised 
by  the  density  of  the  urine  —  low  density  indicating  that  the 
quantity  of  urine  passed  in  twenty-four  hours  is  large,  and  high 
density  the  contrary — but  judged  more  accurately  by  ascertain- 
ing what  is  the  actual  flow  of  urine  in  twenty-four  hours.  A 
urine  may  be  only  slightly  albuminous,  but  if  it  be  of  low  den- 
sity (under  1012)  and  the  daily  quantity  between  three  and  four 
pints,  the  total  loss  of  albumen  will  be  very  considerable,  and  the 
existence  of  renal  disease  strongly  indicated.  Indeed,  of  all 
urines  there  is  none  more  surel}^  indicative  of  Bright's  disease 
than  a  pale,  dilute,  abundant  urine  which  is,  at  the  same  time, 
more  or  less  albuminous.  On  the  other  hand,  as  a  rule,  with 
very  few  exceptions,  when  the  urine  is  only  slightly  albuminous, 
and  at  the  same  time  dense  and  high  colored,  Bright's  disease 
is  not  present,  and  the  albuminuria  is  owing  either  to  pyrexia 
or  to  some  impediment  in  the  circulation  of  the  blood. 

The  kinds  of  deposit  which  indicate  most  strongly  the  exist- 
ence of  organic  renal  disease  are,  (a)  very  abundant  ones,  con- 
taining casts  and  much  renal  epithelium;  (6)  those  containing 
numerous  casts  and  cells  in  a  state  of  fatty  degeneration.  The 
least  indicative  of  primary  renal  disease  of  serious  import,  are, 
blood  casts,  and  very  transparent  casts  in  scanty  numbers. 

3.  When  the  urine  is  found  permanently  albuminous,  and 
there  exists  neither  pyrexia  nor  thoracic  disease,  nor  other 
recognizable  condition  which  can  account  for  the  albumen,  the 


ALBUMEN    IN    THE    UKINE.  199 

inference  is  almost  irresistible  that  there  exists  a  primary 
organic  disease  of  the  kidneys.  The  association  of  other 
symptoms  will  usually  confirm  tliis  diagnosis.  {See  Bright's 
Disease.) 

It  has  been  stated  that  it  is  possible  to  distinguish  secondary 
and  functional  albuminuria  from  albuminuria  depending  on 
disease  of  the  kidneys,  by  the  fact  that  certain  odorous  and 
pigmentary  substances  when  taken  internally  make  their  ap- 
pearance in  the  urine  in  the  former  case  (as  in  health)  but  not 
in  the  latter.  The  observations  of  Dr.  Dyce  Duckworth  do  not 
support  this  conclusion.  He  found  that  iodine,  santonine,  tur- 
pentine, and  oil  of  juniper  passed  through  the  kidneys,  and 
appeared  in  the  urine,  of  persons  affected  with  undoubted 
disease  of  the  kidneys.  Some  exceptional  cases  were,  however, 
encountered.^ 

Pathology  op  Albuminuria. 

It  would  be  out  of  place  in  a  practical  treatise  to  discuss  fully  the 
various  theories  which  have  been  advanced  in  recent  years  to  explain 
the  presence  of  albumen  in  morbid  urine.  The  subject,  however,  is  of 
so  much  interest,  and  has  attracted  so  much  attention,  that  a  short 
review  may  fitly  be  here  inserted,  giving  in  outline  the  views  of  path- 
ologists on  this  vexed  question. 

As  a  preliminary  inquiry  it  must  be  considered  whether  albuminuria 
is  an  exclusively  morbid  phenomena,  or  whether  the  urine  may  in  the 
normal  condition  contain  a  certain  quantity  of  albumen — a  quantity  so 
minute  as  to  escape  detection  by  the  ordinary  tests.  The  appearance  of 
albumen  in  functional  albuminuria  would  by  the  last  view  be  simply  an 
exaggeration  of  a  physiological  condition.  We  should  thus  have  a  sen- 
sible and  insensible  albuminuria,  analogous  to  sensible  and  insensible 
perspiration.  The  systematic  testing  of  the  urine,  especially  in  candi- 
dates for  life  insurance,  has  brought  to  light  the  frequency  with  which 
albuminuria  occurs  when  organic  disease  of  the  kidneys,  or,  indeed,  of 
any  other  organ,  cannot  be  suspected  {see  above — Functional  Albumi-- 
nuria).  It  is  now  certain  that  a  sensible  albuminuria  is  of  much  com- 
moner occurrence  in  healthy  persons  than  has  been  hitherto  supposed. 
Some  of  the  constituents  of  the  urine  which  were  once  considered  exclu- 
sively morbid,  have,  by  the  use  of  finer  methods  of  testing,  been  found 
to  exist  in  minute  quantities  under  perfectly  normal  conditions.  For 
example,  it  has  been  shown  that  minute  traces  of  sugar  exist  in  normal 
urine — and  analogy  would  suggest  that  albumen  also  may  in  the  future 
be  shown  to  be  an  ingredient  of  the  normal  secretion  of  the  kidney, 
although,  perhaps,  present  only  at  certain  periods  of  the  day.  Such  a 
view  is  already  held  by  some  physicians  {see  Senator,  "Die  Albuminurie 
in  gesunden  und  kranken  zustande,"  Berlin,  1882).  The  majority  of 
pathologists,  however,  still  hold  that  every  appearance  of  albumen  in 
the  urine  is  morbid,  although  it  may  not  necessarily  point  to  a  diseased 
condition  of  the  kidneys. 

1  St.  Bart.  Eeports,  vol.  iii.  p.  215. 


200  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

How  comes  it  to  pass  that  while  so  many  other  substances  are  removed 
from  the  blood  by  the  kidneys,  the  albumen  is  retained?  To  this  ques- 
tion mainly  two  answers  have  been  given.  The  first  is  that  of  Von 
Wittich/  who  believed  that  in  the  glomeruli  albumen  really  was  removed 
from  the  blood,  but  that  it  was  afterwards  reabsorbed  in  the  tubules  and 
served  to  nourish  their  epithelium.  This  view  has  met  with  many  oppo- 
nents, and  direct  contradiction  has  been  given  to  it,  by  the  experiments 
mentioned  below,  which  showed  no  coagulated  albumen  in  the  glomerular 
capsule,  when  the  kidney  was  boiled,  or  when  treated  with  alcohol  or 
osmic  acid  immediately  after  removal  from  the  body.  The  view  to 
which  authorities  are  now  most  inclined  is  that  advocated  by  Heiden- 
hain.^  He  accepts  the  opinion  of  Bowman  that  the  urinary  salts  and 
water  are  removed  in  the  glomeruli,  and  that  the  specific  urinary  con- 
stituents, such  as  urea,  are  secreted  by  the  epithelium  of  the  urinary 
tubules.  The  separation  of  the  water  and  salts,  however,  is  not  a  mere 
filtration  as  formerly  supposed.  The  glomerular  tuft  is  covered  by  a 
layer  of  flat  epithelium,  which,  according  to  Heidenhain,  is  an  active 
agent  in  removing  the  water  and  salts  from  the  blood,  but  keeps  back 
the  albumen,  and  prevents  it  reaching  the  urine  at  all.  We  have,  in 
fact,  a  true  secretion,  the  glomerular  epithelium  acting  towards  the 
water  and  salts,  as  the  tubular  epithelium  towards  the  urea,  uric  acid, 
etc.  Moreover,  any  lesion  of  this  epithelial  layer,  or  a  deficiency  in  its 
supply  of  nutrition,  would  cause  it  to  lose  part  of  its  function  and  per- 
mit the  passage  of  albumen  into  the  urine. 

Support  is  lent  to  this  opinion  by  a  consideration  of  the  part  of  the 
kidney  into  which  albumen  is  exuded  when  present  in  the  urine.  Varied 
experiments  have  now  placed  it  beyond  doubt  that  the  albumen  is,  for 
the  greater  part  at  least,  poured  out  in  the  glomerular  capsule.  The 
experiments  have  been  conducted  in  two  ways.  The  kidneys  of  amphi- 
bia have  a  double  blood  supply.  The  glomeruli  are  supplied  from  the 
renal  artery,  while  the  tubules  are  supplied  by  a  sort  of  portal  vein, 
which  springs  from  the  veins  of  the  lower  extremity.  Nussbaum^  showed 
that  by  ligaturing  the  renal  artery  in  frogs  he  could  shut  off  the  blood 
supply  from  the  glomeruli,  while  leaving  that  of  the  tubules  intact.  He 
then  produced  an  artificial  albuminuria  in  frogs  by  the  injection  of  egg- 
albumen  into  the  anterior  abdominal  vein ;  but  he  found  that  the  excre- 
tion of  albumen  immediately  stopped  when  he  ligatured  the  renal  artery, 
although  other  substances  were  still  secreted  by  the  intact  epithelium  of 
the  tubules.  It  could,  therefore,  be  concluded  that  in  this  case  albumen 
was  only  secreted  by  the  glomeruli.  Another  method  employed  was  that 
of  coagulating  the  albumen  in  situ,  by  treating  the  kidney  with  various 
coagulating  agents  immediately  after  removal  from  the  body.  For  this 
purpose  Cornil*  used  osmic  acid,  Ribbert^  strong  alcohol,  and  Posner® 
boiled  the  kidney  for  a  short  time.  When  sections  of  the  kidney  treated 
in  this  way  were  examined,  a  mass  of  coagulated  albumen  could  be  seen 
not  only  in  the  tubes,  but  in  the  space  between  the  glomerular  tuft  and 
its  capsule.     Hence,  it  must  be  inferred  that  usually  the  albumen  is 

1  Virch.  Arch.,  x.  p.  325. 

-  Hermann's  Handb.  der  Phvsiologie,  Bd.  v.,  part  1. 

«  Pfliiger's  Arch.,  xvii.  p.  580.  *  Journ.  de  lAnat.,  1879. 

s  Clblatt.  f.  Med.  Wissen.,  1879.  ^  Virch.  Arch.,  79,  p.  311. 


ALBUMKxV    IN    THE     U  K  I  N  K  .  201 

secreted  by  the  glomeruli.  Senator  finds  an  exception  to  this  in  the 
case  of  venous  congestion,  where  he  believes  that  the  albumen  is  first 
removed  in  the  tubules,  since  the  increase  of  pressure  in  the  venous 
system  will  be  felt  here  before  it  reaches  the  glomeruli. 

The  general  conditions  which  give  rise  to  albuminuria  may  be  classi- 
fied as  follows  : 

I. — Alterations  in  the  Composition  of  the  Blood. 

Mention  has  already  been  made  of  the  classic  experiments  of  Bernard, 
Lehmann,  and  Stokvis,  by  which  it  was  shown  that  certain  foreirjn  albu- 
mens, when  present  in  the  blood,  passed  over  into  the  urine  unchanged. 
Such  albumens  are  egg-albumen  and  haemoglobin,  which  are  more  dif- 
fusible than  serum-albumen  ;  while  others,  such  as  syntonin,  myosin,  and 
alkali  albuminate,  being  less  diffusible,  remain  in  the  bloodvessels  (Leh- 
mann). The  presence  in  the  digestive  tract  of  albuminous  bodies  in 
excess,  may  be  followed  by  their  absorption  and  excretion  by  the  kid- 
neys, in  the  unchanged  state.  The  late  Sir  Kobert  Christison  pointed 
out,  in  1839,  that  the  urine  of  a  person  who  ate  much  cheese  might  con- 
tain albumen.  Bernard,  Stokvis,  Lehmann,  and  many  others,  have  also 
shown  that  the  use  of  uncooked  eggs  as  an  article  of  diet,  or  an  exces- 
sive use  of  them  when  cooked,  may  lead  to  the  presence  of  egg-albumen 
in  the  urine.  The  question  of  a  "food  albuminuria"  has  been  investi- 
gated by  Parkes,  and  more  recently  by  Brunton  and  Power*  and  Sparks 
and  Bruce.''  They  have  proved  that  albumen  may  occur  in  the  urine 
after  taking  food ;  and  if  present  before  food,  it  is  increased  in  amount 
during  digestion.  Such  observations,  however,  do  not  prove  that  the 
albumen  absorbed  is  at  once  excreted  by  the  kidneys,  for  changes  in  the 
blood  circulation  are  coincident,  and  they  also  may  lead  to  disturbance 
of  the  renal  function.  It  has  been  surmised  that  the  albumen  found  in 
the  urine  differs  slightly  from  ordinary  serum-albumen.  Brunton  and 
Power  investigated  the  coagulating-point  of  the  albumen,  and  found 
that  the  albumen  after  food  did  in  some  cases  coagulate  at  a  lower  tem- 
perature than  ordinary  serum-albumen,  and  that  the  earlier  products  of 
pancreatic  digestion  showed  the  same  phenomenon.  Their  experiments, 
however,  did  not  give  constant  results.  Lupine ^  asserts  that  the  albu- 
men passed  after  food  is  more  diffusible,  and  more  easily  transformed 
into  peptone  by  artificial  digestion  than  that  passed  during  fasting.  It 
is  not  improbable  that  special  forms  of  albumen,  such  as  hemialbumose, 
peptones,  and  possibly  transition  stages  between  serum-albumen  and 
these,  may  be  absorbed  from  the  digestive  tract  and  excreted  in  the 
urine.  Peptones,  it  is  alleged,  may  be  absorbed  from  pathological  exu- 
dations, as  in  croupous  pneumonia,  and  during  the  breaking  down  of 
purulent  formations  in  various  parts  of  the  body.  It  is  asserted  that  in 
fevers  and  certain  other  conditions,  peptones  may  be  formed  in  the  blood 
itself  by  a  peculiar  fermentative  process,  and  may  then  appear  in  the 
urine.     (See  Senator,  loc.  cit.  p.  8.) 

The  excretion  of  other  forms  of  albumen  may,  however,  lead  to  the 
exudation  of  serum-albumen  itself.     Lehmann  and  Stokvis  showed  that 

1  St.  Bart.  Eeports,  vol.  xiii.  2  Med.-Chir.  Trans.,  vol.  Ixii. 

3  Kevue  Mensuelle,  1880,  p.  343. 


202  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

albuminuria  did  not  end  with  the  removal  of  all  the  foreign  albumen 
injected  into  the  blood,  but  that  a  quantity  of  serum-albumen  was 
passed  for  sometime.  It  is,  therefore, probable  that  the  passage  through 
the  kidney  of  such  foreign  albumen  may  irritate  the  organ  and  lead  to 
permanent  changes.  Seramola^  believes  that  the  lesion  of  the  kidney 
in  Bright's  disease  is  thus  produced  by  the  continued  excretion  of  unas- 
similated  albuminoid  matters  which  accumulate  in  the  blood.  His 
opinion,  however,  seems  to  rest  on  insufficient  experimental  data. 

The  occurrence  of  functional  albuminuria  is  by  some  authors  attri- 
buted to  derangements  of  digestion  (dyspeptic  albuminuria).  The  late 
Dr.  Murchison^  also  advocated  the  admission  of  a  hepatic  albuminuria. 
The  liver,  he  believed,  might  be  so  overworked  as  to  allow  a  portion  of 
albumen  to  pass  over  into  the  blood  in  an  unassimilated  state,  to  be 
afterwards  removed  by  the  kidneys. 

With  reference  to  other  constituents,  the  relation  of  the  composition 
of  the  blood  to  albuminuria  has,  as  yet,  been  insufficiently  worked  out. 
Dr.  Newman,^  however,  has  shown  experimentally  that  the  amount  of 
albumen  secreted  is  increased  by  an  accumulation  of  urea  in  the  blood. 

II. — Alterations  in  the  Circulation  of  Blood  through  the  Kidneys. 

These  may  consist  of  changes  in  the  quantity  of  blood  supplied  to  the 
kidneys,  in  the  blood  pressure,  or  in  the  rate  of  blood  flow.  Our  knowl- 
edge of  the  action  of  these  changes  is  derived  mainly  from  experimental 
pathology ;  but  it  is  extremely  difficult,  and  in  some  cases  impossible,  to 
vary  one  set  of  relations  apart  from  the  others,  and,  therefore,  the  re- 
sults of  the  experiments  and  the  deductions  drawn  from  them  are  some- 
what conflicting. 

If  the  renal  artery  be  closed  for  a  few  minutes  and  then  reopened, 
the  secretion  of  urine  is  stopped  for  a  time,  and  only  gradually  re- 
established. The  urine  passed  after  the  reopening  of  the  artery  con- 
tains a  quantity  of  albumen,  which  gradually  disappears  as  the  flow  of 
urine  becomes  normal.  (Hermann*  and  Overbeck.^)  A  parallel  to  this 
experiment  is  probably  seen  in  the  algid  stage  of  cholera.  The  supply 
of  blood  to  the  kidneys  is  then  interrupted,  and  the  secretion  stopped ; 
but  in  the  stage  of  reaction,  if  the  patient  survive,  the  urine  is  found  to 
contain  albumen,  which  gradually  disappears  as  convalescence  progresses. 
Hermann  also  showed  that  mere  narrowing  of  the  renal  artery,  without 
absolute  occlusion,  would  cause  a  similar  result.  It  cannot,  however,  be 
concluded  that  the  results  are  due  to  anaemia  of  the  kidney.  They  have 
been  variously  referred  to  lowering  of  blood  pressure,  increase  of  blood 
pressure  from  accumulation  of  corpuscles  in  the  glomerulus  during  the 
stasis,  to  slowing  of  the  blood  stream,  and  to  loss  of  nutrition  of  the 
glomerular  epithelium. 

Similarly,  it  is  a  matter  of  every-day  clinical  experience  that  hyper- 
semia  of  the  kidneys  is  accompanied  by  albuminuria.  Here,  however, 
we  have  again  the  same  complication  of  relations,  vascular  tension  and 
blood  flow  being  alike  altered. 

1  Kevue  Mensuelle,  1880,  p.  239;  also  Progres  Medical,  1883. 

2  Diseases  of  the  Liver,  2d  edit.,  p.  573. 

^  Journ.  of  Anatomy  and  Phvs.,  vol.  xii.  p.  608. 

*  Sitzungsb.  d.  Wien.  Acad., "1861.  '"  Idem,  1863. 


ALliUMEN    IN    THE    URINE.  203 

It  has  been  very  generally  believed  that  increase  of  arterial  tension 
would  cause  albuminuria.  This  seemed  to  be  proved  clinically  by  Dr. 
Mahomed,'  who  showed  that  the  appearance  of  albumen  in  the  urine 
as  a  sequel  of  scarlet  fever  is  preceded  by  a  period  of  high  vascular 
tension. 

Experimentally,  also,  the  same  conclusion  is  arrived  at.  Thus,  Rob- 
inson^ and  Frerichs''  found  that  by  ligaturing  the  abdominal  aorta 
below  the  renal  arteries  and  then  removing  one  kidney,  they  caused 
albumen  to  appear  in  the  urine  coming  from  the  remaining  kidney. 
More  recently  Lepine  (loe.  cit.)  has  produced  rise  of  blood  pressure  and 
consequent  albuminuria  by  injecting  a  quantity  of  salt  solution  into  the 
crural  vein  of  a  dog. 

An  astonishing  theory  was  propounded  by  Runeberg  ("iJeutsch,  Arch, 
f.  Klin.  Medic,"  vol.  23),  as  the  result  of  his  experiments  on  the  diffusion 
of  albuminous  fluids  through  animal  membranes.  He  attempted  to 
show  that  the  transudation  of  albumen  was  favored  by  a  diminution  in 
the  difference  of  pressure  on  the  two  sides  of  the  dialyzing  membrane, 
and  hindered  by  an  increase  of  such  difference.  Applying  his  view^  to 
the  kidney,  he  asserted  that  the  cause  of  albuminuria  was  low  vascular 
pressure,  which  produced  increased  permeability  of  the  walls  of  the 
Malpighian  tufts.  Runeberg's  results  were,  however,  entirely  contra- 
dicted by  the  careful  experiments  of  Dr.  Newman  (loc.  cit),  and  also 
by  those  of  Bamberger^  and  Gottwalt.^  Heideuhain,  too,  has  shown 
that  Runeberg's  own  figures  will  not  bear  the  interpretation  he  himself 
placed  upon  them,  while  Bamberger  points  out  that  Runeberg  has  paid 
no  attention  to  coincident  variations  of  blood  flow.  It  must,  therefore, 
be  accepted  that  low  vascular  pressure  is  not  a  cause  of  albuminuria. 

It  is  not  safe,  however,  to  assert  that  increased  pressure  in  the  Mal- 
pighian capillaries  will  alone  cause  albuminuria,  for  it  is  impossible 
entirely  to  eliminate  other  influences  which  may  at  least  assist  the  high 
pressure  in  its  work. 

There  is  now  a  fairly  general  agreement  that  slowing  of  the  blood 
stream  plays  a  very  active  part  in  producing  albuminuria  (Bamberger 
and  Heidenhain).  Dr.  Mahomed*^  groups  the  two  conditions,  increased 
pressure  and  retardation  of  blood  flow,  as  the  chief  factors  in  the  causa- 
tion of  albuminuria. 

The  modes  in  which  these  various  changes  in  the  blood  system  of  the 
kidney  may  be  brought  about,  are  of  course  numerous.  Increase  of 
blood  pressure  in  the  kidney  may  be  caused  by  general  rise  of  blood 
pressure,  or  locally  through  the  vaso-raotor  nerves.  The  fact  that  punc- 
ture of  the  floor  of  the  fourth  ventricle  may  produce  albuminuria  is 
probably  to  be  explained  by  coincident  injury  to  the  vaso-motor  centre. 
Bamberger  believes  that  the  vaso-motor  system  may  be  efficient  in  pro- 
ducing many  cases  of  functional  albuminuria.  Weakness  of  the  heart's 
action  may  cause  slowing  of  the  blood  stream  in  the  kidney,  and 
venous  obstruction  may  produce  not  only  slowing  of  the  blood  stream, 
but  also  increase  of  pressure  in  the  glomeruli. 

1  Med.  Chir.  Trans.,  vol.  57.  -'  Med.  Chir.  Trans.,  vol.  26. 

^  Die  Brio;ht'sche  Nierenkraiik,  Braunscliweio-,  1851. 

*  Wien.  Med.  Wochensch.,  1881. 

»  Zeitsch,  f.  Physiolog.  Cliemie.,  IV.  p.  423.  «  Glasgow  Med.  Journ.,  1884. 


204  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

III. — Alterations  in  the  Structure  of  the  Kidney. 

These  are  admitted  by  all  to  be  efficient  causes  of  albuminuria. 

The  change  in  structure  may  affect  either  the  kidney  epithelium  or 
the  bloodvessels.  If  it  be  accepted  that  the  glomerular  epithelium  in 
the  normal  state  prevents  the  albumen  exuding  from  the  blood,  it  is 
plain  that  any  diseased  condition  of  this  epithelium  will  allow  the  albu- 
men to  pass  through.  A  similar  function  has  been  advocated  by 
Senator  for  the  epithelium  of  the  renal  tubes.  Not  only  may  gross 
lesions  of  these  epithelial  layers  cause  albuminuria,  but  it  is  also  con- 
sidered that  simple  lesions  of  nutrition  may  lead  to  loss  of  function. 
Thus,  Cohnheim^  asserts  that  every  important  change  of  circulation 
renders  the  secreting  membrane  permeable  by  albumen.  The  lesions, 
then,  which  have  been  described  above,  such  as  narrowing  or  oblitera- 
tion of  the  renal  artery,  changes  in  blood  pressure,  and  slowing  of  the 
blood  stream,  would  produce  their  effects  by  causing  disordered  nutri- 
tion of  the  epithelium  covering  the  glomeruli.  The  nutritive  change 
may  be  temporary,  or  may  lead  to  permanent  changes.  The  proofs  of 
this  view,  however,  are  difficult  to  obtain,  and  it  must  at  present  be 
considered  as  sub  judice. 

Increase  of  interstitial  tissue,  as  is  found  in  granular  kidney,  may  be 
accompanied  not  only  by  changes  in  the  epithelium,  but  by  hindrance 
to  the  blood  flow,  from  compression  of  the  capillaries  by  the  new 
growth. 

The  effect  of  structural  changes  in  the  bloodvessels  is  manifest  in 
the  albuminuria  which  usually  accompanies  amyloid  degeneration  of 
the  kidney.  Here  we  have  as  the  initial  lesion  a  degeneration  of  the 
walls  of  the  bloodvessels,  which  renders  them  more  permeable  to 
albumen. 

Such  are  the  individual  causes  of  albuminuria,  but  it  will  be  gathered 
from  what  has  been  said  that  the  causes  do  not  act  singly,  and  however 
much  stress  may  be  laid  upon  one  change  in  any  particular  pathological 
state,  that  change  is  almost  invariably  assisted  in  its  action  by  others. 
Thus  in  the  albuminuria  of  fevers  we  have  structural  change,  as  shown 
by  the  cloudy  degeneration  of  the  renal  epithelium,  we  have  also  changes 
in  the  blood  pressure  and  in  the  rate  of  blood  flow,  while  it  is  by  no 
means  improbable  that  the  albumen  of  the  blood  may  also  undergo 
modification. 

XI.— SUGAE  IN  UKINE. 

In  1862  Schunck^  announced  that,  when  healthy  urine  was 
subjected  to  boiling  with  acids,  it  gradually  deposited  a  resinous 
substance,  and  acquired  the  power  of  reducing  the  oxide  of 
copper — in  other  words,  that  the  presence  of  a  substance  having 
the  properties  of  glucose  became  apparent  in  it.  This  impor- 
tant observation  probably  explains  the  discrepant  conclusions  of 
those  who  have  sought   for  sugar  as  a  normal  constituent  of 

1  Allgemeine  Pathologie,  vol.  ii.  p.  815. 

2  PMlosophical  Msiguzine,  March,  1862. 


SUGAR    IN    THIS    URKVE.  206 

healthy  urine.  Briickc'  and  licnce  JoneH  wore  alvvays  ahle  to 
obtain  sugar  from  healthy  urine  in  not  inconsiderable  quanti- 
ties. Bence  Jones^  obtained  as  much  as  0.8  to  1.7  grain  per 
pint.  If  natural  urine  contain  a  substance,  capable  of  yielding 
sugar  by  a  simple  decom[)osition,  it  is  quite  possible  that  the 
sugar  found  by  these  observers  was,  either  partly  or  wholly,  an 
educt  of  the  analysis,  and  not  a  preexisting  constituent  of  the 
urine.  This  much  is  certain,  that  healthy  urines  and  the  vast 
majority  of  morbid  urines,  do  not  contain  sugar  in  quantity 
capable  of  being  detected  by  ordinary  direct  testing.  At  the 
same  time  it  is  probable  that  minute  traces  of  sugar,  as  of  nearly 
every  other  substance  dissolved  in  the  blood,  exist  in  the  urine. 
These  traces,  however,  granting  them  to  exist,  have  no  clinical 
significance  whatsoever.  When  sugar  is  present  in  quantity 
sufiicient  to  interest  the  medical  practitioner,  it  is  detectable 
with  certainty  by  direct  testing;  and  conversely  when  direct 
testing  reveals  the  presence  of  sugar,  it  is  invariably  a  grave 
pathological  sign,  and  not  a  matter  of  mere  physiological  curi- 
osity. In  the  following  observations  I  have  solely  in  view  sugar 
in  these  sensible  proportions. 

Tests  for  Sugar  in  Urine.  (Qualitative  Testing.) — Fre- 
quent mistakes  are  committed  in  regard  to  the  presence  or 
absence  of  sugar  in  urine,  not  only  by  physicians  and  surgeons, 
but  even  by  professed  chemists.  More  than  once,  specimens 
have  been  brought  to  me  with  the  statement  that  an  analytic 
chemist  had  found  a  small  quantity  of  sugar,  but  in  which  no 
sugar  really  existed — certain  fallacious  appearances,  to  which  I 
shall  presently  refer,  having  been  mistaken  for  genuine  evi- 
dence. Without  proper  precautions,  sugar  testing,  like  all  other 
testing,  is  open  to  fallacies;  but  with  moderate  care  and  observ- 
ance of  a  few  fixed  rules,  the  detection  of  sugar  is  a  matter  of 
the  most  perfect  certainty  and  ,of  exquisite  delicacy.  Before 
proceeding  to  describe  the  best  means  for  this  purpose,  I  will 
say  a  word  about  those  tests  which  are  in  common  use,  but 
which  are  either  unreliable  or  insufficiently  delicate — namely, 
Moore's  test,  and  the  fermentation  test. 

1.  Boiling  with  Liquor  Potassoe^Moore' s  Test). — When  urine  con- 
taining sugar  is  boiled  with  an  equal  bulk  of  liquor  potasses,  the 

^  Iwanoff  has  pointed  out  some  fallacies  in  Brucke's  process.  He  considers 
that  the  greater  part  of  the  sugar  obtained  by  Briicke  did  not  preexist  in  the  urine, 
but  was  derived  from  some  other  constituent  (inlican)  by  the  reagents  employed. 
Iwanoff  concludes  that  minute  traces  of  sugar  do  exist  frequently,  but  hy  no 
means  constantly  in  healthy  urine.  (Meissner's  B^richt  in  Henle  and  Pfei.fer's 
Zeitsch.  for  1861,  p.  323.)  In  Bence  Jones's  proce-s  sulphuretted  hydn^gen  was 
emploj'ed  instead  of  oxalic  acid;  but  even  with  tins  moditication,  the  urine  would 
be  rendered  acid,  and  tliei'e  would  be  great  probability  of  sugar  tieing  produced 
from  indican  during  the  long  process  of  evaporation  of  the  large  quantities 
(1000  c.c.)  of  urine  used. 

2  Journal  of  the  Chemical  Society,  1862,  p.  22. 


206  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

mixture  darkens,  and  eventually  assumes  a  brandy-brown  color. 
From  its  easy  application,  this  test,  as  a  preliminary  step,  and 
for  negative  evidence,  is  of  great  convenience.  It  has,  however, 
two  faults — (a)  it  is  wanting  in  delicacy,  and  (6)  it  is  liable  to  a 
notable  fallacy.  Moore's  test  does  not  answer  clearly  until  the 
proportion  of  sugar  rises  to  about  0.3  per  cent.,  or  one  grain 
and  a  half  to  the  ounce,  By-and-by  we  shall  come  to  a  test  twelve 
times  more  delicate  than  this. 

Again,  all  high-colored  urines  of  high  density  become  darker 
when  boiled  with  liquor  potassse,  although  free  from  sugar;  and 
albuminous  urines,  even  when  not  high-colored,  darken  sensibly 
under  the  same  treatment.  This  occurs  with  perfectly  fresh 
liquor  potasses ;  but  if  the  test  have  been  kept  in  ordinary  white- 
glass  bottles,  it  very  speedily  becomes  impregnated  with  lead, 
which  it  attracts  from  the  glass,  and  this  offers  an  additional 
source  of  error.  The  liquor  potassse  kept  in  the  wards  of  the 
Ro^'al  Infirmary  was  found  largely  impregnated  with  lead, 
although  it  had  not  been  in  use  more  than  about  six  weeks. 
Liquor  potassse  thus  vitiated,  when  boiled  with  certain  urines, 
turns  them  of  a  dark  porter-brown  color.  This  is  something 
quite  different  from  the  slight  deepening  of  the  tint  which  has 
just  been  alluded  to,  and  it  only  occurs  in  albuminous  urines,  and 
not  even  in  all  of  these.  In  acute  Bright's  disease,  especially 
when  there  was  blood  in  the  urine,  or  when  the  albumen  was 
abundant  and  associated  with  free  discharge  of  renal  epithelium, 
the  change  of  color  was  most  intense;  and  in  one  such  case  the 
existence  of  sugar  had  been  inferred  therefrom,  and  announced 
to  the  patient  and  his  friends,  by  the  medical  attendant,  "Where 
the  proportion  of  albumen  was  small,  and  renal  desquamation 
slight,  the  lead-tainted  liquor  potassae  did  not  produce  so  marked 
an  effect.  In  such  urines  a  slight  darkening  of  color  only 
ensued,  much  to  the  same  degree  as  occurred  with  fresh  liquor 
potassse.  It  was  never  found  that  liquor  potassse  containing  lead 
produced  a  dark  brown  coloration  Avith  non-albuminous  urines, 
provided,  of  course,  that  they  were  sugar  free.  The  usual  slight 
deepening  of  the  tint  took  place,  but  not  anything  conspicuously 
greater  than  with  fresh  and  pure  liquor  potassse, 

2,  The  Fermentation  Test. — When  saccharine  urine  is  mixed 
with  yeast  and  kept  in  a  warm  place,  it  speedily  ferments  with 
the  production  of  alcohol  and  evolution  of  carbonic  acid ;  and 
as  no  other  substance  is  capable  of  undergoing  this  transforma- 
tion, the  occurrence  of  fermentation  with  yeast  is  certain  proof 
of  the  presence  of  sugar. 

Applied  to  ordinary  diabetic  urine,  fermentation  affords  very 
clear  indications.  The  most  convenient  and  elegant  way  of 
applying  it  is  the  following:  A  few  crumbs  of  German  yeast 
are  put  into  the  bottom  of  a  test-tube  ;  this  is  then  filled  up  to 


SUGAR    IN    THE    URINE.  207 

the  brim  with  the  suspected  urine,  covered  with  an  evaporating 
dish  or  saucer,  and  then  inverted.  The  dish  and  inverted  tube 
are  now  set  aside  in  a  warm  place — say  on  the  mantel-piece. 
The  urine  soon  begins  to  ferment,  gas  collects  in  the  top  of  the 
inverted  tube  and  expels  a  })ortion  of  the  urine;  and  if  sugar 
be  abundant,  the  gas  accumulates  in  such  quantities  that  all  the 
urine  is  driven  out  before  it.  There  is  a  precaution,  however, 
to  be  observed.  Some  specimens  of  yeast  spontaneously  evolve 
bubbles  of  gas  :  it  is  therefore  desirable,  where  the  indication  is 
doubtful,  to  perform  a  parallel  experiment  with  the  same  yeast 
mixed  with  simple  water,  so  that  the  amount  of  gas  spontaneously 
yielded  b}^  it  may  be  ascertained.  German  yeast  is  exceedingly 
convenient  for  fermentation  experiments,  and  it  has  now  come 
into  such  common  use  that  a  pennyworth  may  be  purchased  in 
almost  any  baker's  shop. 

There  are  two  drawbacks  to  the  clinical  application  of  this 
test — (a)  it  takes  some  hours  for  its  accomplishment,  and  (6)  it 
does  not  sufiice  for  the  discovery  of  minute  quantities.  Urine 
is  capable  of  absorbing  somewhere  about  its  own  bulk  of  car- 
bonic acid,  so  that,  unless  the  amount  evolved  be  greater  than 
this,  there  will  be  no  accumulation  of  gas  in  the  top  of  the  tube, 
and  consequently  no  visible  sign  of  fermentation.  According 
to  my  experience,  urine  containing  0.5  per  cent.,  or  tw^o  grains 
and  a  half  to  the  ounce  and  under,  yield  no  sign  to  the  fermen- 
tation test.  Fermentation  is  therefore  a  considerably  less  sen- 
sitive method  of  sugar-testing  than  Moore's  plan  of  boiling  with 
liquor  potassse. 

There  is,  however,  another  manner  of  applying  fermentation 
to  the  detection  of  sugar,  which  is  much  simpler  and  even  more 
delicate  than  the  foregoing  —  namely,  by  comparison  of  the 
specific  gravity  of  the  suspected  urine  before  and  after  fermenta- 
tion. This  proceeding  will  be  examined  more  in  detail  under 
the  head  of  quantitative  testing ;  but  I  may  here  observe  that 
considerably  less  sugar  than  one  per  cent,  may  be  detected  by 
the  lowering  of  the  density  after  fermentation. 

3.  Reduction  Tests. — The  action  of  grape-sugar  on  a  number 
of  metallic  salts  in  alkaline  solution  is  attended  by  a  reduction 
of  the  oxides  which  they  contain  to  a  lower  degree  of  oxidation, 
or  to  the  metallic  state.  A  similar  reducing  action  has  the  effect 
of  changing  the  color  of  several  organic  solutions.  Accord- 
ingly some  of  these  substances  are  resorted  to  as  valuable  sugar 
tests,  both  qualitative  and  quantitative. 

The  metallic  salts  best  adapted  for  this  purpose  are  those  of 
copper,  bismuth,  silver,  chromium,  mercury,  and  tin ;  but  as 
the  oxide  of  copper  is  the  most  universally  known,  and  with 
proper  precautions  the  most  striking  and  sensitive,  I  shall  here 
confine  my  remarks  solely  to  it. 


208  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

The  ordinary  mode  of  using  the  copper,  or,  as  it  is  called, 
'Trommer's  test,  is  to  add  a  drop  or  two  of  a  solution  of  sulphate 
of  copper  to  the  suspected  urine  in  a  test-tube.  Liquor  potassae 
is  then  added  in  excess,  and  the  mixture  boiled.  If  the  proper 
proportions  have  been  observed,  a  red  deposit  of  suboxide  of 
copper  falls  when  sugar  is  present.  Applied  in  this  rough  way 
the  operation  of  the  test  is  very  unsatisfactory.  If  the  copper 
be  in  excess,  a  quantity  of  the  protoxide  remains  undissolved 
and  causes  confusion.  The  liquor  potassse  likewise  obscures 
the  result  by  producing  an  intense  dark-brown  color  if  sugar  be 
abundant,  and  the  boiling  continued  beyond  a  few  seconds.  In 
consequence  of  these  and  other  objections,  Trommer's  test  is 
regarcled  with  very  little  favor  by  many  practitioners,  who  rely 
in  preference  on  the  easy  and  ready,  though  less  delicate,  method 
of  boiling  with  liquor  potassse.  But  all  the  uncertainty  attend- 
ing the  employment  of  the  copper  test  arises  from  a  faulty 
application,  and  not  from  inherent  imperfection.  When  skil- 
fully used,  it  possesses  a  delicacy  and  certainty  that  render  all 
other  reagents  superfluous. 

The  first  necessity  is  to  abandon  the  rough  method  above 
sketched,  and  to  prepare  beforehand  a  test  solution  which 
shall  combine  the  copper  and  the  alkali  in  due  proportion. 
This  is  accomplished  by  dissolving  sulphate  of  copper  in 
strong  liquor  sodse  with  the  aid  of  tartrate  of  potash.  The 
exact  formula  for  this  solution  (Fehling's  standard  copper 
solution)  will  be  given  hereafter. 

Having  prepared  the  test  fluid,  it  is  employed  in  the  follow- 
ing manner :  Fill  a  test-tube  to  the  depth  of  three-quarters  of 
an  inch  or  so  with  the  copper  solution;  heat  until  it  begins  to 
boil,  and  then  add  a  drop  or  two  of  the  suspected  urine.  If  it 
be  ordinary  diabetic  urine,  the  mixture,  after  an  interval  of  a 
few  seconds,  will  turn  suddmly  of  an  intense  opaque-yellow 
color,  and  in  a  short  time  an  abundant  yellow  or  red  sediment 
falls  to  the  bottom.  If,  however,  the  quantity  of  sugar  present 
be  small,  the  suspected  urine  is  added  more  freely,  but  not  beyond 
a  volume  equal  to  that  of  the  test  employed.  In  this  latter  case  it  is 
necessary  to  raise  the  mixture  once  more  to  the  boiling-point. 
It  is  then  allowed  to  cool  slowly.  If  no  suboxide  has  been 
thrown  down  when  it  has  become  cold,  then  the  urine  may 
with  certainty  be  pronounced  sugar-free. 

The  points  of  importance  in  this  proceeding  are  :  (a)  to  boil  the 
test  first,  and  not  the  urine;  and  (6)  to  use  an  excess  of  the  test. 

The  first  point  is  of  importance,  because  the  test-solution  is 
apt  to  deteriorate  by  keeping,  unless  preserved  hermetically 
sealed  from  the  air.  When  deteriorated  by  exposure  to  the 
atmosphere,  a  deposit  of  suboxide  takes  place  from  it  on  simple 
boiling.     Boiling  the  test,  therefore,  is  a  trial  of  its  perfection. 


SUGAR    IN    THE    URINE.  209 

If  it  remain  clear  for  a  minute  or  two  after  eVjulliiion,  tlic  solu- 
tion is  in  order,  and  the  testing  may  be  proceeded  witli ;  but 
if  the  solution  become  somewhat  opaque,  and  a  red  deposit 
presently  fall  from  it,  this  deposit  must  be  first  filtered  from 
the  clear  fluid,  which  is  thereby  again  rendered  fit  for  use;  or 
— which  is,  indeed,  the  better  plan — a  fresh  supply  of  the  test 
is  prepared.  The  deterioration  here  spoken  of  arises  from  the 
conversion  of  a  portion  of  the  tartaric  acid  into  racemic  acid, 
which,  equally  with  sugar,  has  a  reducing  power  on  the  oxide 
of  copper,  and,  when  present,  of  course  corrupts  the  analysis. 

The  necessity  for  using  an  excess  of  the  test  applies  equally  to 
an  ordinary  diabetic  urine,  as  well  as  to  one  which  contains 
only  a  small  proportion  of  sugar,  and  has  a  composition  ap- 
proaching the  natural  standard  ;  but  as  the  reason  for  employing 
an  excess  is  not  the  same  in  the  two  instances,  and  as  there  are 
important  diflierences  in  the  operation  of  the  test  in  the  two 
classes  of  urine,  I  shall  call  attention  to  them  separately. 

(a)  Method  of  Testing  Ordinary  Diabetic  Urine. — Practically,  the 
urine  of  a  diabetic  patient,  where  the  disease  is  in  full  career, 
may  be  regarded  as  a  solution  of  grape-sugar  in  simple  water. 
The  natural  constituents  are  in  such  small  proportion,  owing  to 
the  increased  flow,  that  they  do  not  sensibly  interfere  with  the 
operation  of  the  test. 

If,  after  the  test  has  been  heated  to  ebullition,  one  drop  of 
diabetic  urine  be  added,  the  reaction  occurs  almost  instantane- 
ously, and  the  suboxide  falls  of  a  brick-red  color  at  once;  but 
if  several  drops  of  the  same  urine  be  added,  the  precipitate  is  a 
rich  yellow.  This  difl:erence  in  color  is  merely  a  question  of 
excess  or  deficiency  of  the  test.  When  the  copper  exceeds  the 
sugar,  and  the  solution  still  retains  its  blue  color,  the  suboxide 
falls  red ;  but  if  the  sugar  exceed  the  copper,  and  the  blue  color 
have  disappeared,  the  suboxide  falls  yellow. 

The  common  mode  of  proceeding — that  is,  boiling  the  urine 
first,  and  then  adding  the  reagent — is  very  objectionable,  inas- 
much as  it  may  betray  the  operator  into  a  too  sparing  use  of  the 
test,  and  thereby  entail  a  failure  of  the  reaction.  If  the  sugar 
preponderate  greatly  over  the  copper,  no  precipitation  whatever 
ensues,  because  the  excess  of  sugar  dissolves  the  suboxide,  and 
forms  with  it  a  transparent  yellow  solution.  This  statement 
may  be  readily  verified  b}^  boiling  some  diabetic  urine  in  a  test- 
tube,  and  then  dropping  in  the  test-solution.  The  first  few 
drops  occasion  a  dense,  muddy,  yellow  opacity  in  the  topmost 
layer;  but  when  the  tube  is  shaken  the  precipitate  is  redis- 
solved.  On  adding  more  of  the  test,  however,  the  opacity 
becomes  permanent,  and  an  abundant  deposit  presentl}-  sub- 
sides. 

14 


210  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

(b)  Method  of  Testing  where  the  Quantity  of  Sugar  is  Small  and  the 
Natural  Constituents  Approximate  their  usual  Proportions, — The 
discovery  of  sugar  in  such  a  urine  is  much  more  difficult  than 
in  the  former  case.  The  ordinary  ingredients  of  the  urine — 
urea,  uric  acid,  pigmentary  and  otlier  extractives,  the  alkaline 
and  earthy  salts — seriously  affect  the  delicacy  of  the  test.  If 
grape-sugar  be  dissolved  in  simple  water,  such  is  the' sensitiveness 
of  the  reaction  that  one  grain  in  ten  pints  yields  a  perceptible 
deposit;  but  when  dissolved  in  urine,  a  considerably  larger 
quantity  may  be  present  and  the  test  fail  to  reveal  its  existence. 
Nevertheless,  enough  of  delicacy  remains  to  satisfy  all  the  re- 
quirements of  clinical  research.  A  still  greater  delicacy  can  be 
imparted  to  the  test  by  the  method  suggested  by  Seegen  ("  Brit. 
Med.  Journ.,"  1872,  i.  469).  The  urine  is  filtered  repeatedly 
through  animal  charcoal  until  it  is  completely  colorless — a  little 
distilled  water  is  then  passed  through  the  filter,  and  to  this  water 
the  test  is  applied  in  the  usual  way.  An  exceedingly  minute 
trace  of  sugar  (0.01  per  cent.)  can  be  detected  by  this  procedure. 

Urine  of  the  kind  here  considered — with  a  minute  propor- 
tion of  sugar,  and  the  ordinary  ingredients  almost  natural — is 
met  with  in  the  early  stage  of  diabetes,  before  the  disease  has 
acquired  its  full  developm'ent ;  also  in  convalescence  from  the 
less  severe  forms;  and  not  unfrequently  towards  the  fatal  close 
of  the  complaint.  Even  in  well-marked  diabetes  there  are 
conditions  under  which  the  urine  temporarily  returns  nearly  to 
its  natural  state.  These  are :  abstinence  from  saccharine  and 
amylaceous  food,  and,  afo7'tiori^  abstinence  from  all  food;  accord- 
ingly, the  morning  urine,  after  the  prolonged  fast  of  the  night, 
may,  in  the  less  severe  cases,  be  found  ahnost  sugar-free.  A 
like  effect  follows  the  advent  of  an  intercurrent  inflammation, 
as  of  the  lungs  or  lining  membrane  of  the  bowels. 

In  testing  for  sugar  in  urines  of  this  description  certain  pre- 
cautions are  rigidly  demanded,  otherwise  considerable  quan- 
tities of  sugar  may  be  wholly  overlooked.  The  most  important 
of  these  is  to  use  a  great  excess  of  the  test.  When  the  copper 
solution  is  added  drop  by  drop  to  healthy  urine,  at  a  boiling 
heat,  the  blue  color  is  immediatel}^  discharged,  although  not 
a  particle  of  sugar  be  present,  and  the  urine  assumes  a  deep 
amber  tint.  The  degree  to  which  urines  exercise  this  decolor- 
izing property  varies  with  their  strength — that  is,  with  their 
concentration.  A  dense  urine  (sugar-free)  will  discharge  the 
color  from  nearly  its  own  bulk  of  Fehling's  standard  solution ; 
but  even  the  most  dilute  natural  urines — those  that  are  almost 
colorless — have  a  very  considerable  power  this  way.  Whatever 
be  the  nature  of  the  transformation  here  involved,  it  is  certain 
that  when  the  color  of  the  test  has  been  thus  discharged,  the 
copper  it  contains  is  no  longer  capable  of  being  precipitated  by 


S  U  G  A  R    1 M     '1'  1 1  K    U  R  1 N  E .  211 

any  sugar  that  may  be  present  in  the  urhie;  and  the  Hul>oxide 
is  not  thrown  down  until  sueh  an  amount  of  the  sohition  lias 
been  added  that  tlie  mixture  retains  a  distinctly  green  tint  after 
being  raised  to  the  boiling-point.  To  secure  an  excess  of  the 
test,  the  most  certain  method  is  to  heat  the  solution  fii-st,  as 
already  recommended,  and  to  add  the  suspected  urine  after- 
wards. Another  advantage  is  secured  by  this  proceeding.  When 
the  suspected  urine  contains  a  considerable  quantity  of  earthy 
phosphates,  the  precipitation  of  these  by  the  alkali  of  the  test  is 
apt  to  cause  embarrassment.  The  phosphates  fall  in  light,  dirty- 
white  tiocculi,  which  might  be  mistaken  by  the  unwary  for  a 
deposit  of  suboxide.  When  the  test  and  urine  are  mixed 
together  before  applying  heat,  or  the  test  is  added  to  the  Ixnling 
urine,  the  earthy  phosphates  fall  in  such  fine  fiakes  that  the 
transparency  of  the  mixture  is  impaired;  but  if  the  urine  be 
added  to  the  boiling  test,  the  mixture  retains  its  translucency 
from  the  phosphates  being  thrown  down  in  denser  masses;  and 
by  holding  the  tube  between  the  eye  and  the  light,  the  flakes 
are  seen  floating  in  a  clear,  bluish-green  medium. 

In  the  class  of  saccharine  urines  now  under  consideration, 
the  suboxide  is  always  precipitated  yellow,  never  red.  The 
operation  of  the  test  is  exceedingly  distinctive,  and  takes  place 
as  follows :  The  copper  solution  having  been  heated  to  ebul- 
lition, and  something  less  than  an  equal  bulk  of  the  suspected 
urine  having  been  added,  the  mixture  is  again  raised  to  the 
boiling-point.  It  then  changes  to  an  intense  opaque  yellowish- 
green,  and  slowly  a  bright -yellow  deposit  subsides.  If  the 
urine  contains  less  than  half  a  grain  per  cent,  of  sugar,  the  pre- 
cipitation does  not  take  place  immediately,  but  occurs  as  the 
liquid  cools — in  five,  ten,  or  twenty  minutes,  and  the  manner 
of  the  change  is  peculiar.  First,  the  mixture  loses  its  trans- 
parency, and  passes  from  a  clear  olive-green  to  a  light  greenish 
opacity,  looking  just  as  if  some  drops  of  milk  had  fallen  into 
the  tube.  This  green  milky  appearance  is  quite  characteristic 
of  sugar.  B}^  this  proceeding  one-tenth  of  a  grain  per  fluid- 
ounce,  or  less  than  one-fortieth  of  a  grain  per  cent.,  can  with 
certainty  be  detected,  and  any  quantity  below  this  has  no 
pathological  signification,  and  is  a  matter  of  only  physiological 
interest. 

Some  of  the  natural  urinary  ingredients,  and  especially  urre 
acid,  have  been  stated  to  possess  the  power  of  reducing  the 
oxide  of  copper  to  a  state  of  suboxide,  and  of  becoming  thereby 
the  source  of  a  notable  fallacy  in  using  this  test  for  the  detec- 
tion of  sugar.  In  practice,  however,  no  fear  need  be  enter- 
tained on  this  score ;  I  have  over  and  over  again  treated  urines 
containing  an  excess  of  uric  acid,  and  even  urines  thick  with 
the  amorphous  urate  deposit,  with  the  test-solution  at  a  boiling 


212  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

heat,  but  have  never  obtained  the  least  resenablance  to  the  sugar 
reaction.^  It  is,  however,  to  be  borne  in  mind,  that  if  urine 
be  boiled  with  the  test /or  a  considerable  time,  a  reddish  deposit 
falls,  and  the  mixture  assumes  a  muddy,  dirty  fawn  appearance, 
although  no  sugar  be  present.  This  reddish  deposit  appears  to 
consist  of  the  earthy  phosphates  tinged  red  by  some  of  the  sub- 
oxide, reduced,  perhaps,  through  the  instrumentality  of  uric  acid. 
But  this  reddish  deposit  is  only  'produced  after  prolonged  boiling, 
and  prolonged  boiling  is  of  all  things  the  most  to  be  avoided, 
because  the  most  utterly  useless,  in  performing  the  test.  If 
simply  raising  the  fluid  to  the  boiling-point,  and  then  allowing 
it  to  cool  in  a  warm  place,  as  in  a  jug  of  hot  water  or  on  the 
hob,  fail  to  yield  an  indication  of  sugar,  no  amount  of  boiling 
will  develop  a  trustworthy  reaction. 

To  recapitulate,  the  best  method  of  detecting  sugar  in  urine 
is  as  follows :  Pour  some  of  the  prepared  test-liquid  into  a  nar- 
row test-tube  to  the  depth  of  three-quarters  of  an  inch;  heat 
until  it  begins  to  boil;  then  add  two  or  three  drops  of  the  sus- 
pected urine.  If  the  sugar  be  abundant,  a  thick  yellowish 
opacity  and  deposit  of  yellow  suboxide  are  produced  (and  this 
changes  to  a  brick-red  at  once  if  the  blue  color  of  the  test  remain 
dominant).  If  no  such  reaction  ensue,  go  on  adding  the  urine 
until  a  bulk  nearly  equal  to  the  test  employed  has  been  poured 
in;  heat  again  to  ebullition;  and,  no  change  occurring,  set  aside 
without  further  boiling.  If  no  milkiness  is  produced  as  the 
mixture  cools,  the  urine  may  be  confidently  pronounced  free 
from  sugar,  for  no  quantity  above  a  fortieth  of  a  grain  per  cent, 
can  escape  such  a  search,  and  any  quantity  below  that  is  devoid 
of  clinical  significance. 

Fehling's  test  may  be  rendered  portable  by  compressing  the 
solid  ingredients  into  pellets  as  suggested  by  Dr.  Pavy,^  or  by 
enclosing  the  fluid  in  glass  capsules  (Dr.  Ralfe^).  In  these  ways 
the  stability  of  the  test  is  also  permanently  insured. 

The  Indigo-carmine  Test. — If  a  solution  of  indigo-carmine 
(sulph.-indigotate  of  soda)  be  rendered  alkaline  by  carbonate  of 
soda  and  boiled  with  a  small  quantity  of  grape  sugar,  the  indigo- 
blue  becomes  reduced  to  indigo-white,  which  causes  the  blue 
solution  to  assume  a  yellow  color.  This  test,  originally  intro- 
duced by  Mulder,  has  been  recently  recommended  by  Dr.  Oliver,* 
who  makes  use  of  it  in  the  convenient  form  of  test-papers.  Two 
test-papers,  one  saturated  with  indigo-carmine,  and  the  other 

1  Hagen  and  Miiller  have  found  that  urine  free  from  sugar  may  show  from 
0.087  to  0.37  per  cent,  of  reducing  agents.  See  Lancet,  1879,  i.  p.  606;  also 
Pfluger's  Archiv,  Bd.  xvi.  S.  567. 

2  Lancet,  1880,  i.  p.  172.  These  "  pellets "  may  be  obtained  from  ^Y.  T. 
Cooper,  chemist,  26  Oxford  Street,  London. 

»  Lancet,  1880,  ii.  p.  192.  *  Bedside  Urii.e  Testing,  1883. 


SUGAR    IN    TJFE    URINE.  213 

with  carbonate  of  soda,  are  diBsolved  in  a  Biiiall  quantity  of" 
water,  the  result  being  a  clear,  blue  solution.  To  this,  one  drop 
of  the  suspected  urine  is  added,  and  the  mixture  boiled,  when, 
if  sugar  be  present,  the  blue  color  will  successively  give 
place  to  reddish-violet,  different  shades  of  red,  and  finally  to  a 
pale  yellow  tint.  On  standing,  the  solution  reabsorl^s  oxygen 
from  the  air,  and  gradually  returns  to  its  original  hue.  In  Dr. 
Oliver's  hands,  this  test  has  proved  not  only  more  convenient, 
but  more  delicate  than  Fehling's. 

The  Picric  Acid  Test. — When  a  solution  of  picric  acid  is  boiled 
with  grape-sugar,  in  the  presence  of  liquor  potassse,  the  yellow 
picric  acid  is  reduced  to  picramic  acid,  which  has  a  deep  red 
color.  Dr.  Gr.  Johnson^  has  introduced  this  reaction  as  a  test 
for  diabetic  sugar  in  urine;  but  the  method  of  applying  the 
test  will  be  more  fully  discussed,  when  considering  its  applica- 
tion to  quantitative  analysis. 

Estimation  of  the  Quantity  of  Sugar  in  Urine.  (Quan- 
titative Testing.) — In  early  times  medical  men  judged  of  the 
quantity  of  sugar  in  diabetic  urine  by  the  amount  of  syrup 
yielded  on  evaporation.  This  was  a  very  rude  as  well  as  trouble- 
some proceeding.  A  much  readier  and  not  less  precise  method 
was  to  calculate  the  sugar  from  the  specific  gravity.  Dr.  Henry 
drew  up  a  table,  which  Prout  afterward  extended  and  improved, 
showing  at  a  glance  how  much  solid  matter  per  pint  was  con- 
tained in  urines  at  different  densities.  When  the  urine  voided 
amounts  to  several  quarts  a  day,  and  the  natural  urinary  ingredi- 
ents have  sunk  to  a  very  low  proportion,  the  secretion  resembles 
a  solution  of  grape-sugar  in  pure  water.  In  this  condition  the 
density  is  a  moderately  accurate  measure  of  the  quantity  of 
sugar;  but  it  is  still  far  from  absolute  correctness,  as  may  be 
judged  from  the  following  table,  drawn  up  from  a  number  of  my 
analyses : 

Table  showing  the  uncertain  relation  of  the  specific  gy^avity  to  the  proportion  of 

sugar  tvhere  the  daily  flow  of  urine  rajiged  between  nine  and  thirteen  pints. 

Specific  gravity.  Sujjar  per  imperial  pint. 

1045 :  875  grains. 

1043 972   " 

1042 683   " 

1041 920   " 

1041 931   " 

1040 nil   " 

1039 683   " 

1035 875   " 

1034 645   " 

1033 635   " 

But  when  the  flow  of  urine  is  no  more  than  two  or  three  pints 
a  day,  the  natural  ingredients  come  to  hold  something  like  their 

^  Albumen  and  Suo'ai"  Testino-.     London,  18P!4. 


214 


ABNORMAL    SUBSTANCES    IN    THE    UKINE, 


normal  proportions,  and  contribute  very  sensibly  to  raise  he 
density.  Accordingly  with  the  diminished  flow  there  is  a  very 
greatlj"  lessened  proportion  between  the  specific  gravity  and  the 
percentage  of  sugar.  The  annexed  table  shoAvs  this  relation  in 
the  urines  of  the  same  patients  when  the  daily  excretion  had  been 
reduced  by  dietetic  means  to  between  two  and  three  pints. 


Table  showing  the  lessened  and  siiU  more  uncertain  relation  of  the  specific 
gravity  to  the  quajitity  of  sugar  where  the  daily  flow  ranged  between  two  and 
three  pints. 


Specific  gravity. 

1044 
1042 
1041 
1041 
1039 
1039 
1039 
1039 
1036 
1035 
1034 
1034 


Sugar  per  imperial  pint. 

625  grains. 

553  " 
591 

498  " 

568  " 

608  •' 

600  " 
446 

377  ■' 

471  •' 

486  ^' 
312 


On  comparing  these  two  tables,  it  is  seen  that  the  density 
holds  a  much  less  constant  relation  to  the  proportion  of  sugar 
when  the  daily  flow  is  scanty  than  when  it  is  abundant.  It  is 
also  seen  that  in  the  former  case  a  given  degree  of  density 
indicates  a  much  lower  proportion  of  sugar  than  in  the  latter. 
The  mean  density  in  the  first  table  is  1039.3,  and  in  the  second 
nearly  the  same — 1038.6;  but  the  propoi'tion  of  sugar  is  much 
greater  in  the  first,  where  it  averages  813  grains  per  pint,  than 
in  the  second,  where  it  is  only  511  grains. 

Of  the  more  accurate  processes  there  are  two  peculiarly 
eligible  for  practical  use — the  one  on  account  of  its  speedy  per- 
formance, and  the  other  on  account  of  its  easy  application. 

1.  Volumetrical  Processes. — These  depend  in  principle  on  the 
fact  that  there  is  a  fixed  relation  between  the  amount  of  sugar 
present  and  the  amount  of  metallic  salt  or  picric  acid  reduced 
by  its  action.  Thus,  Fehling  found  that  one  molecule  of 
grape-sugar,  or  180  parts,  decomposed  exactly  five  molecules,  or 
1246.8  parts,  of  sulphate  of  copper.  Accordingly  he  prepared 
a  solution  of  copper  of  standard  strength,  and  applied  it  to 
fluids  containing  grape-sugar;  and  the  quantity  of  these  required 
to  decompose  a  fixed  volume  of  the  standard  solution  furnished 
an  exact  measure  of  the  sugar  they  contained. 

The  solutions  which  have  been  used  for  the  estimation  of  sugar 
in  the  urine  are  those  of  sulphate  of  copper,  either  in  Fehling's 


SUGAR    IN    THE    URINE.  215 

method,  or  in  the  modification  of  it   Hiif^f^ested    by  \)v.   Tavy, 
and  of  picric  acid,  as  applied  by  Dr.  G.  Joiinson,' 

a.  Fehling's  Illethod. — Fehling's  standard  solution  is  prepared 
according  to  the  following  prescription: 

Crystals  of  sulphate  of  copper  .         .     84.G4  gnimiues,  or    90.',  grains. 
Neutral  tartraie  of  potash         .         .   173        '  "  304"'     " 

Solution    of    caustic    soda    of    sp. 

2;r.  1.12  .....        480  c.cm.,  or  4  fluidounces. 

,    Add  water  to  make  up  1000  cuhic   centimetres   or  G   fluidounces. 

Every  10  cb.  centira.  corresponds  to  0,06  gramme  of  grape- 
sugar,  and  200  grains  to  1  grain  of  sugar.  The  apparatus  re- 
quired for  the  performance  of  the  analysis  is  described  and 
figured  at  pp.  36  and  37. 

Mode  of  Performing  the  Analysis. — Measure  off  200  grains  of 
the  standard  solution  in  the  200-grain  tube,  pour  this  into  the 
flask,  and  add  about  twice  its  volume  of  water;  then  place  over 
a  spirit-lamp  to  boil.  While  the  copper  solution  is  being  heated, 
the  urine  to  be  analyzed  should  be  diluted  with  water  to  aknown 
degree.  In  the  ease  of  ordinary  diabetic  urines,  the  best  dilu- 
tion is  one  in  ten.  This  is  obtained  by  carefully  filling  the  6  oz, 
measure  with  water  to  the  depth  of  4J  ounces,  and  then  adding 
urine  so  as  to  make  up  exactly  5  ounces.  The  mixture  will 
then  contain  exactly  one-tenth  of  urine,  (When  the  quantity 
of  sugar  in  the  urine  is  very  small,  a  dilution  of  one  in  five,  or 
even  the  undiluted  urine,  may  be  employed,) 

The  next  step  is  to  fill  the  burette  (which  is  graduated  to 
grains)  with  the  diluted  urine  to  0,  Then  proceed  to  add  it,  in 
successive  small  portions,  to  the  boiling  copper  solution,  until 
the  blue  color  has  entirely  disappeared.  After  each  fresh  addi- 
tion from  the  burette  the  mixture  should  be  raised  to  the  "boil- 
ing-point, and  then  allowed  to  stand  a  few  seconds,  so  that  the 
precipitated  copper  may  subside,  and  the  observer  may  see,  by 
holding  the  flask  between  the  eye  and  the  light,  whether  the 
mixture  still  retains  any  blue  color.  As  soon  as  the  blue  color 
has  disappeared  the  analysis  is  complete,  and  the  quantity  of 
diluted  urine  employed  may  be  read  off.  The  percentage  of 
sugar  in  the  urine  can  now  be  readily  calculated.  Suppose  125 
grains  had  been  added  from  the  burette ;  this  represents  one- 
tenth,  or  12.5  grains,  of  undiluted  urine,  and  contains  exactly 
one  grain  of  sugar;  by  dividing  12.5  into  100,  the  percentage  of 
sugar  in  grains  is  obtained;  or^^.|-=8;  the  urine  contains  8 
per  cent,  of  sugar. 

If  the  metrical  system  is  preferred,  the  process  would  be  car- 

^  Knapp's  method,  by  which  the  reduction  of  cyanide  of  mercury  to  the 
metallic  state  is  applied  for  the  estimation  of  sugar,  is  not  recommended  for 
urine  testing. 


216  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

ried  out  in  the  following  manner :  Into  a  burette  graduated  in 
cubic  centimetres,  10  cubic  centimetres  of  urine  are  placed  and 
diluted  to  100  cubic  centimetres,  with  water.  Place  in  the  flask 
10  cubic  centimetres  of  the  Fehling's  solution  (representing  0.05 
gramme  of  sugar),  and  dilute  with  about  twice  its  volume  of 
water ;  then  boil  as  before.  The  amount  of  diluted  urine  re- 
quired to  reduce  the  copper  in  the  Fehling's  solution  is  then 
determined,  and  the  calculation  made  as  follows :  Suppose  that 
12  cubic  centimetres  of  the  diluted  urine  were  required;  this 
would  represent  1.2  cubic  centimetre  of  urine,  which  would 
contain  0.05  gramme  of  sugar.  The  number  of  grammes  con- 
tained in  100  cubic  centimetres  of  urine  would  be  obtained  bj 
the  proportion  : 

L2    _  100    .    ^  _  100  X  0.05  _  4  26 
005  ~  'x^  '  '  ^  "         1.2  ~    *     ■ 

To  determine  more  exactly  the  point  at  which  the  whole  of  the  copper 
has  been  reduced,  when  the  end  of  the  reaction  is  believed  to  have  been 
reached,  a  portion  of  the  fluid  in  the  flask  may  be  filtered.  The  filtrate 
should  be  quite  free  from  blue  color,  and  if  acidified  with  acetic  acid  and 
a  solution  of  potassium  ferrocyanide  added,  no  brown  color  should  be 
produced.  If,  by  these  means,  copper  should  be  found  in  the  filtrate, 
sufl&cient  urine  has  not  been  added,  and  the  process  must  be  repeated 
from  the  beginning.  On  the  other  hand,  if  a  few  drops  of  Fehling's 
solution  added  to  the  filtrate  should  give  a  deposit  of  copper  oxide  on 
boiling,  too  much  urine  has  been  added,  and  the  process  must  again  be 
repeated.  For  clinical  purposes,  however,  the  disappearance  of  the  blue 
color  can  be  determined  by  the  eye  with  quite  sufficient  exactitude. 

h.  Dr.  Pavy's  Method. — Dr.  Pavy  has  introduced  a  modifica- 
tion of  Fehling's  method,  by  which  the  reduced  oxide  of  copper 
is  retained  in  solution  by  ammonia.  The  action  of  the  sugar  is 
then  shown,  not  by  precipitation  of  the  copper  oxide,  but  simply 
by  the  discharge  of  the  blue  color  of  the  solution.  The  solution 
recommended  by  Dr.  Pavy  is  composed  as  follows  : 

Cupric  sulphate    .......         4.158  grammes. 

Potassic  sodic  tartrate  ......       20.4  " 

Potash  (caustic) 20.4  " 

Strong  ammonia  (sp.  gr.  0.880)    ....  300         c.cm. 
Water  to  1  litre. 

Of  this  solution  10  cubic  centimetres  are  decolorized  by  0.005 
gramme  of  sugar.  The  test  may  also  be  kept  either  in  the  form 
of  pellets  or  enclosed  in  glass  tubes  each  containing  10  cubic 
centimetres.  To  make  the  solution  the  tartrate  of  potash  and 
caustic  potash  are  dissolved  together  in  one  portion  of  the  water 
and  the  sulphate  of  copper  in  another  portion.     Tbe  solution  of 


SUGAR    IN    THE    URINE.  217 

sulphate  of  copper  is  then  poured  into  that  of  the  potash  salts, 
and  to  this  the  ammonia  is  added,  the  whole  bein^  diluted  with 
water  to  the  required  amount.  The  pellets  are  of  two  kinds — 
one  containing  the  tartrate  of  potash  and  copper  sulphate 
together  with  ammonium  chloride,  the  other  containing  the 
caustic  potash.  The  two  pellets  are  dissolved  separately  and 
the  solutions  mixed,  when  the  whole  will  represent  10  cubic 
centimetres  of  the  original  solution.  To  apply  the  test  a  burette 
is  tilled  with  the  urine  to  be  examined,  diluted  to — preferably — 
1  part  in  20.  There  must  now  be  placed  in  a  small  flask,  10 
cubic  centimetres  of  the  copper  solution  diluted  with  20  cubic 
centimetres  of  water,  and  the  w^hole  raised  to  the  boiling-point. 
The  diluted  urine  is  then  run  in  from  the  burette  drop  by  drop, 
until  the  whole  of  the  blue  color  has  disappeared  from  the  solu- 
tion. The  amount  of  diluted  urine  thus  required,  divided  by 
twenty,  will  give  the  number  of  cubic  centimetres  of  urine  con- 
taining 0.005  gramme  of  sugar.  During  the  process  air  must 
be  excluded  from  the  flask,  for  the  colorless  solution  of  cuprous 
oxide  in  ammonia  soon  absorbs  oxygen,  forming  again  the  blue 
solution  of  cupric  oxide.  For  details  of  the  process  and  for  a 
convenient  table,  giving  the  amount  of  sugar  per  1000,  cor- 
responding to  the  number  of  cubic  centimetres  of  urine  used, 
the  reader  is  referred  to  Dr.  Pavj^'s  paper  in  the  "Lancet,"  I. 
p.  376,  1884. 

The  process  has  the  advantage  of  determining  the  end-point 
of  the  reaction  more  easil}^  than  can  be  done  by  Fehling's 
method,  and  the  ammoniated  solution  is  also  more  stable  than 
Fehling's  solution. 

c.  Johnson's  Method. — As  previously  mentioned,  this  test  de- 
pends on  the  power  of  grape-sugar  to  reduce  a  yellow  solution 
of  picric  acid,  in  the  presence  of  caustic  potash,  to  a  red  solu- 
tion of  picramic  acid, — the  depth  of  the  red  color  depending  on 
the  amount  of  sugar  present.  In  applying  the  test  a  standard 
solution  of  picramic  acid  is  required,  with  the  color  of  which, 
the  result  of  boiling  the  urine  with  picric  acid  and  potash  may 
be  compared.  A  standard  solution  representing  the  color  pro- 
duced by  the  presence  of  ^  grain  of  sugar  to  the  ounce  of  urine, 
is  found  convenient;  but  since  the  solution  of  picramic  acid  is 
liable  to  change  rapidly  on  exposure  to  light,  it  is  better  to  keep 
as  a  standard,  a  solution  of  acetate  of  iron,  which,  if  made 
according  to  the  following  formula,  will  equal  in  color  the 
standard  picramic  acid  solution. 

Liq.  ferri  perchlor.  fort.    (sp.  gr.  1.338)    .         .  .  .1  drachm. 

Liq.  ammon.  acetat.          (sp.  gr.  1.017)    .         .  '   .  .4        " 

Glacial  acetic  acid             (sp.  gr.  1.065)    .         .  .  .     4        " 

Liq.  ammoniee                   (sp.  gr.  0  959)    .         .  .  .     1        " 
Distilled  water  to  4  ounces. 


218  ABNOEMAL    SUBSTANCES    IN    THE    URINE, 

111  tliis  method  also,  it  is  desirable  to  dilute  the  urine,  before 
examining — say  to  five  or  ten  times  its  volume.  A  drachm  of 
the  diluted  urine  is  then  taken  and  boiled  for  sixty  seconds  with 
30  minims  of  liq.  potassae  and  40  minims  of  concentrated  solu- 
tion of  picric  acid,  sufficient  water  being  added  to  make  four 
drachms  of  the  solution.  At  the  end  of  the  boiling,  if  the  solu- 
tion is  found  to  be  less  than  four  drachms,  it  must  be  raised  to 
that  amount  by  the  addition  of  more  water.  This  part  of  the 
process  is  conveniently  carried  out  in  a  long  test-tube  marked  at 
the  height  of  four  drachms.  The  deep  red  solution  must  now 
be  diluted  until  its  color  exactly  equals  that  of  the  standard 
solution.  This  is  done  in  a  stoppered  tube,  twelve  inches  long 
and  three-quarters  of  an  inch  in  diameter,  graduated  into  10  and 
100  equal  divisions.  Attached  to  this  tube  is  another  smaller 
tube,  containing  the  standard  solution.  A  quantity  of  the 
boiled  urine  and  test,  is  poured  in  a  large  tube,  until  the  tenth 
division  is  reached  and  distilled  water  is  added  carefully  until 
the  colors  of  the  liquid  in  the  graduated  tube  and  that  in  the 
smaller  tube  are  exactly  alike.  The  number  of  degrees  of  dilu- 
tion required  to  produce  this  is  then  read  off.  During  the  boil- 
ing the  urine  was  diluted  four  times,  and  hence,  if  it  then  just 
equalled  in  color  the  test  solution  it  would  have  contained  one 
grain  of  sugar  to  the  fluid-ounce.  If  further  dilution  were  re- 
quired to  bring  it  to  this  standard,  say  from  ten  to  thirty-five 
divisions,  3.5  grains  to  the  ounce  would  be  indicated. 

Previous  to  the  admixture  with  the  test,  however,  the  urine 
was  diluted — sa}^  ten  times.  Hence,  the  result  above  obtained 
must  be  multiplied  by  ten,  to  obtain  the  number  of  grains  of 
sugar  per  ounce  of  the  original  urine. 

A  full  account  of  the  method  will  be  found  in  Dr.  Johnson's 
treatise  on  "Albumen  and  Sugar  Testing,"  London,  1884.  The 
apparatus  required  are  made  by  E.  Cette,  36  Brooke  Street, 
Holborn,  E.G. 

2.  Differential  Density  Method. — This  method  of  estimating 
sugar  combines,  as  I  believe,  more  perfectly  than  any  other, 
the  twin  advantages  of  ease  and  accuracy.  It  is  founded  on 
the  diminution  of  density  suffered  by  saccharine  urine  when 
fermented  with  yeast.  The  specific  gravity  of  an  ordinary 
diabetic  urine  ranges  from  1035  to  1050.  When  it  has  under- 
gone fermentation,  and  all  the  sugar  is  converted  into  alcohol 
and  carbonic  acid,  the  specific  gravity  is  found  to  have  sunk 
to  1009,  to  1002,  or  even  below  1000.  This  falling  off  in  the 
density  arises  from  two  distinct  yet  necessarily  associated  causes 
— namely,  first,  the  destruction  of  the  sugar,  which  was  the 
cause  of  the  high  density  of  the  original  urine ;  and,  second, 
the  presence  of  the  generated  alcohol  in  the  fermented  product. 
Now  the  loss  of  density  from  these  causes  must  evidently  stand 


SUGAR    IN    THE    URINE.  2\U 

Yjroportionul  to  the  quantity  of  sugar  originally  jjiescnt  in  tlio 
urine,  and  must  consu(|uently  iurnisli  a  measure  of  its  quantity. 

The  experimental  data  on  vvliich  this  method  is  founded 
are  fully  detailed  in  a  paper  published  by  the  author  in  the 
"  Memoirs  of  the  Manehester  Literary  and  Philosophical 
Society"  for  1860;  also  in  a  paper  in  the  "Edinburgh  Monthly 
Journal"  for  October,  1861.  The  mode  of  experimenting  was 
— first  to  ascertain  by  Fehling's  method  how  much  sugar  was 
contained  in  a  certain  diabetic  urine.  The  urine  was  then  fer- 
mented by  means  of  German  yeast — its  specific  gravity  having 
been  previously  ascertained.  In  twenty-four  hours,  after  the 
fermentation  had  ceased,  and  the  scum  had  subsided,  the  density 
was  taken  again,  and  by  subtracting  this  from  the  density  l^efore 
fermentation,  the  "density  lost"  was  ascertained.  And  it  was 
found  that  for  every  grain  of  sugar  contained  in  an  ounce  of 
urine,  one  degree  of  specific  gravity  had  been  lost.  Experi- 
ments were  multiplied  on  diabetic  urine:  corresponding  experi- 
ments made  with  solutions  of  sugar  of  known  strength  in 
healthy  non-saccharine  urine  and  in  pure  water,  and  the  issue 
of  all  was  to  establish  the  conclusion  that  the  number  of  degrees  of 
"  density  lost'''  indicated  as  many  grains  of  sitgar  per  fluid-ounce. 

In  the  practical  application  of  the  method,  the  ordinary  urin- 
ometer  may  be  used  for  taking  the  densities;  but  it  is  well  to 
choose  one  with  a  long  scale,  as  some  of  those  in  use  have  very 
short  ones,  and  it  becomes  impossible  to  read  the  density  accu- 
rately. Still  further  precision  may  be  attained  by  dividing  the 
usual  scale  into  two  parts  on  separate  instruments.  I  have  had 
constructed  for  my  own  use  two  perfectly  corresponding  urin- 
ometers,  on  one  of  which  the  scale  ranges  from  995  to  1025,  and 
on  the  other  from  1025  to  1055,  each  instrument  covering  30 
degrees  of  density.  The  scales  are  thus  rendered  so  long,  and 
the  intervals  between  the  lines  so  great,  that  in  a  clear  urine 
the  specific  gravity  can  be  easily  read  to  a  quarter  of  a  degree ; 
and  even  in  fermented  urine,  which  does  not  regain  its  original 
transparency,  but  continues,  at  least  for  many  days,  more  or  less 
cloudy,  it  can  be  read  with  certainty  to  half  a  degree. 

Another  important  point  is  to  obviate  errors  from  variations 
of  temperature.  If  the  density  before  and  after  fermentation 
be  taken  at  widely  different  temperatures,  an  error  of  serious 
amount  may  creep  into  the  analysis.  The  best  mode  of  avoid- 
ing this  is  to  put  up  a  few  ounces  of  the  unfermented  urine  in 
a  "  companion  phial,"  and  to  place  this  side  by  side  with  that 
set  apart  for  fermentation,  so  that,  at  whatever  temperature  the 
fermented  product  may  be  when  its  density  is  observed,  its  un- 
changed alter  ego  stands  near  it  for  comparison  at  exactly  the 
same  temperature. 


220  ABNORMAL    SUBSTANCES    IN    THE    URINE. 

The  most  convenient  way  of  proceeding  is  the  following : 
About  four  ounces  of  the  saccharine  urine  are  put  into  a  12- 
ounce  bottle,  and  a  lump  of  German  yeast  about  the  size  of  a 
cobnut  or  small  walnut  is  added  to  it.  A  great  excess  of  yeast 
is  used  to  hasten  fermentation,  but  a  little  more  or  a  little  less 
does  not  sensibly  affect  the  result.  The  bottle  is  then  covered 
with  a  nicked  cork  (which  permits  the  escape  of  the  carbonic 
acid),  and  set  aside  on  the  mantel-piece  or  other  warm  place  to 
ferment.  Beside  it  is  placed  a  tightly  corked  4-ounce  phial 
filled  with  the  same  urine  without  any  yeast.  In  about  twenty- 
four  hours  the  fermentation  will  have  ceased,  and  the  scum 
cleared  off"  or  subsided.  The  fermented  urine  is  then  decanted 
into  a  urine-glass,  and  its  specific  gravity  taken ;  at  the  same 
time,  the  density  of  the  unfermented  urine  in  the  companion 
phial  is  observed,  and  the  "density  lost"  ascertained.  Fer- 
mentation is  generally  complete  in  about  eighteen  hours,  if  the 
locality  be  sufficiently  warm;  and  it  is  desirable  to  remove  the 
two  phials  into  a  cool  place  two  or  three  hours  before  the  densi- 
ties are  taken,  in  order  that  they  may  attain  the  temperature  of 
the  surrounding  atmosphere. 

The  two  following  examples  may  serve  as  illustrations  of  the 

method : 

I.  11. 

Density  before  fermentation    .....     1053  1038 

Density  after  fermentation       .....     1004  1013 

Degrees  of  density  lost    ......         49  25 

Grains  of  sugar  per  fluid-ounce       ....         49  25 

If  it  be  desired  to  bring  out  the  result  as  so  much  per  cent., 
this  is  accomplished  by  multiplying  the  number  indicating  the 
"  density  lost"  by  the  coefficient  0.23.  Thus  in  the  first  of  the 
above  examples  49x0.23=11.27,  and  in  the  second  25x0.23= 
5.69,  which  are  the  amounts  of  sugar  respectively  per  100  parts. 

The  time  actually  consumed  in  determining  the  quantity  of 
sugar  in  urine  by  this  method  does  not  exceed  four  or  five 
minutes,  but  the  result  must  be  waited  for  until  the  succeeding 
day;  this  is  its  chief  advantage.  Its  application  is  so  easy,  that 
a  medical  friend  in  attendance  on  a  diabetic  patient  was  able  to 
teach  the  patient's  wife  to  make  the  analysis;  every  morning 
when  he  came,  she  could  give  exact  information  as  to  the 
quantity  of  sugar  excreted  on  the  previous  day. 

Dr.  Hensley^  has  investigated  the  limits  of  error  which  the 
use  of  this  method  involves.  He  finds  that  the  rule  arrived  at 
experimentally — namely,  that  one  degree  of  density  lost  in  fer- 
mentation corresponds  to  one  grain  of  sugar  per  ounce  of  urine 

1  Note  on  Dr.  Eoberts's  method  of  estimating  diabetic  sugar,  by  Philip  J.  Hens- 
ley,  in  vol.  iii.  of  the  St.  Bartholomew's  Hospital  Eeports. 


SUGAR    IN    THE    URINE.  221 

— agrees  very  closely  with  t?)C  theoretical  result  obtained  by 
calculation.  Dr.  Ilensley  concludes  that  if  the  above  rule  be 
applied  to  the  fluid-ounce  measure  of  the  British  Pharrnacoprxiia, 
and  sugar  be  taken  as  dry  crystal lizable  glucose  (CglT/J/j,  the 
result  obtained  is  slightly  too  large,  but  the  excess  above  the 
true  number  is  less  than  its  sixty-fourth  part,  that  is  to  say,  less 
than  1.6  per  cent. 

Optical  Saccharimetrij . — The  property  of  glucose  of  rotating 
the  plane  of  polarization  to  the  right  has  been  taken  advantage 
of  to  estimate  the  quantity  of  sugar  in  diabetic  urine.  The  best 
instruments  for  the  purpose  are  those  of  Mitscherlich  and 
Soleil.  This  method  is  not  so  universally  applicable  as  the 
preceding;  and  the  price  of  the  instruments,  together  with  the 
delicacy  required  in  their  manipulation,  puts  them  almost  out  of 
reach  of  ordinary  practitioners. 

Clinical  Significance  of  Sugar  in  the  Urine. — The  presence 
of  a  large  quantity  of  sugar  in  the  urine  is  the  characteristic 
feature  of  diabetes  mellitus:  but  small  quantities  may  be  pres- 
ent in  a  variety  of  other  circumstances — as  after  eating  exces- 
sively of  amylaceous  or  saccharine  articles  of  food,  from  injury 
or  disease  of  certain  parts  of  the  nervous  system,  from  impedi- 
ments to  respiration,  etc.  This  subject,  however,  can  be  more 
conveniently  treated  in  a  future  page  (see  Physiological  Con- 
siderations relating  to  Diabetes). 


PART  II. 


IRINARY  DISEASES-DISEASES  OF  WHICH  THE  CHIEF  CHAR- 
ACTERISTIC IS  AN  ALTERATION  OF  THE  URINE. 


CHAPTEE    I. 

DIABETES  INSIPIDUS. 

Cases  characterized  by  increased  thirst  and  excessive  dis- 
charge of  a  watery  urine  of  low  specific  gravity,  free  from  sugar 
and  albumen,  are  grouped  together  under  the  general  designa- 
tion of  diabetes  insipidus. 

The  want  of  uniformity  in  the  course  and  symptoms  of  these 
cases,  and  in  the  anatomical  changes  found  after  death,  indicate 
that  several  wholly  distinct  pathological  states  are  included 
under  this  heading. 

Attempts  have  been  made  to  classify  the  cases  according  to 
the  characters  of  the  urine.  Those  in  which  it  was  supposed 
that  the  urine  merely  contained  an  excessive  amount  of  water, 
without  any  alteration  of  the  total  quantity  of  solids  excreted, 
or  of  the  mutual  proportion  of  the  several  solid  ingredients  to 
each  other,  have  been  named  Polydipsia  (or  excessive  thirst) : 
those  in  which  it  was  supposed  that  the  solid  matters,  and 
especially  urea,  were  excreted  in  excessive  quantity,  have  been 
named  Polyuria;  and  those  in  which  it  was  supposed  that  the 
urea  and  other  solids  were  in  diminished  quantity,  have  been 
named  Anazoturia  (Willis). 

This  classification  is,  however,  valueless  in  practice :  both 
from  the  difficulty  of  assigning  a  precise  standard  of  composi- 
tion to  the  urine  under  the  various  conditions  of  existence,  and 
the  tedious  and  difficult  investigations,  extending  over  several 
days,  which  are  required  to  ascertain  the  mean  composition  of 
the  urine  in  any  particular  case. 


224 


DIABETES    INSIPIDUS. 


The  following  account  of  diabetes  insipidus  has  been  drawn 
up  from  an  analysis  of  one  hundred  and  twenty  cases, — either 
collected  from  various  sources  or  observed  by  myself. 

Etiology. — The  liability  to  diabetes  insipidus  is  very  consid- 
erably greater  in  males  than  in  females;  of  one  hundred  cases, 
seventy-two  were  males,  and  twenty-eight  females;  the  age  of 
the  patients  at  the  time  of  invasion  ranged  from  the  extremes 
of  infancy  to  old  age;  but  the  greater  number  occurred  be- 
tween the  ages  of  five  years  and  thirty  years.  In  the  following 
table  an  analysis  is  given  of  the  ages  of  seventy  cases  at  the 
time  of  invasion. 


Infancy 

7  cases. 

From  20-30  years  . 

.     16  cases 

From    5-10  years  . 

.     15      " 

"      30-50     "     . 

.     15      " 

"      10-20     "     . 

.     13      " 

"      50-70     "     . 

.       4      " 

In  two,  if  not  three,  cas^s  the  disease  appeared  to  have  existed 
actually  from  birth. 

In  a  very  large  proportion,  no  exciting  cause  whatsoever  could 
be  assigned  for  the  disorder.  In  the  remainder,  various  cir- 
cumstances were  alleged  with  greater  or  less  probability  to 
have  been  the  exciting  causes.  These  present  considerable 
similarity  to  the  alleged  causes  of  saccharine  diabetes,  and  stand 
in  the  following  order  of  frequency : 


Cerebral  disease  (tubercle,  etc.) 
Blows  on  the  head,  and  falls  . 
Intemperance 

Exposure  to  cold,  and  drinking 
cold  fluids  while  heated 


11 


Previous  febrile  or  inflammatory) 
disease  .....  j 
Hereditary  influence 
Muscular  effort 
Exposure  to  hot  sun  . 
Mental  emotion 


In  several  cases  serious  organic  changes  were  found  in  the 
kidneys.  These  will  be  more  particularly  described  in  con- 
nection with  the  morbid  anatomy  of  the  disease. 

Two  cases  recorded  by  Dr.  W.  Watts  ("  Lancet,"  1848)  are 
referred  by  him  to  syphilitic  disease  and  abuse  of  mercury. 

Hysteria,  grief,  neuralgia,  or  the  influence  of  a  nervous  con- 
stitution, are  also  mentioned  as  determining  causes. 

In  some  of  the  traumatic  cases  the  symptoms  set  in  with 
maximum  intensity  on  the  very  day  of  the  accident ;  in  others 
there  was  at  first  loss  of  consciousness;  and  the  thirst  and.  diu- 
resis came  on  with  the  restoration  of  the  faculties,  or  a  few  days 
after.  In  one  case  severe  nervous  symptoms  continued  for  six 
months  after  a  fall,  and  the  diuresis  first  broke  out  at  the  end  of 
this  period.  In  four  of  the  traumatic  cases  the  symptoms  per- 
sisted for  between  nine  days  and  a  month,  and  then  finally  dis- 
appeared as  the  cerebral  symptoms  subsided ;  in  two  others  the 


ETIOLOGY.  225 

disorder  became  permanent,  and  liad  already  existed  at  tlie  date 
of  the  record,  six  years  in  one  and  seven  years  in  tlie  other.' 

In  the  cases  associated  with  cerebral  disease,  tumor  of  the 
brain  was  found  in  four — and  degeneration  of  the  cell-elements 
in  three  others.  These  cases  will  be  noticed  more  particularly 
when  the  morbid  anatomy  of  the  disease  comes  to  be  treated  of. 
In  a  case  observed  by  myself  (a  shopkeeper  thirty-five  years  of 
age),  the  disease  had  come  on  twenty  months  previously  with 
sudden,  complete,  and  permanent  loss  of  sight,  iirst  in  the  left 
eye,  and  six  months  later  in  the  right.  During  these  twenty 
months  the  patient  had  been  in  the  habit  of  voiding  two  or 
three  gallons  of  urine  daily.  He  was  also  subject  to  curious 
nervous  attacks,  which  recurred  at  irregular  intervals,  and  lasted 
from  half  an  hour  to  periods  of  several  days.  They  consisted 
in  a  perversion  of  intellect,  incoherence,  irrepressible  impulse 
to  go  away  from  the  house,  trembling  of  the  limbs  and  twitch- 
ing of  the  muscles.  Sometimes  the  patient  w^ould  fall  into  an 
epileptiform  fit,  with  loss  of  consciousness,  screaming  and  con- 
vulsions, but  without  foaming  at  the  mouth,  or  biting  the  tongue. 
When  seen  by  me  he  was  totally  blind,  but  the  intellect  was 
perfect,  and  the  general  health — except  during  the  paroxysms — 
was  good.  He  could  walk  twelve  miles  with  ease;  and  in  the 
last  eight  months  he  had  gained  weight  to  the  extent  of  40  lbs. 
The  history  and  general  character  of  the  symptoms  appeared  to 
point  to  the  existence  of  vesicular  parasites  within  the  cra- 
nium. The  three  remaining  cases  of  this  group  w^ere  children 
supposed  to  suffer  from  cerebral  tubercle.  They  all  died  in 
convulsions. 

Of  the  five  cases  attributed  to  intemperance,  the  symptoms 
came  on  in  one  of  them  on  the  day  after  a  severe  bout  of  drink- 
ing, in  which  the  patient  had  been  insensible  for  two  days. 
ISTot  one  of  this  group  is  reported  as  cured ;  and  one  died  in  two 
months. 

Two  cases  followed  exposure  to  cold;  and  two  followed 
copious  drinking  of  cold  fluids  while  the  skin  was  hot  and  per- 
spiring. One  of  the  latter,  related  by  Vigla,  began  with  un- 
quenchable thirst  and  diuresis  on  the  same  day,  and  terminated 
fatally  a  few  months  after. 

Four  cases  followed  variola,  ague,  fever,  and  inflammation  of 
the  bowels;  all  ran  a  very  chronic  course,  and  lasted  from  four 
to  twenty-four  years,  with  good  preservation  of  health;  the  symp- 

1  Dr.  Matthews  Duncan  has  sent  me  the  notes  of  a  case  (re«id  before  the  Edin. 
Obst.  Soc,  June  10,  1874)  of  D.  Insipidus,  in  a  woman  who  miscarried  at  the 
seventh  manth.  Fourteen  years  before  she  had  a  blow  of  great  severitj'  on  the 
back  of  the  head.  Shortly  after  this  she  observed  that  she  drank  a  great  deal  of 
water,  and  had  a  great  flow  of  urine.  This  has  continued  ever  since,  though  she 
has  enjoyed  fair  health,  and  is  the  mother  of  four  healthy  children.  The  qu^ntitv 
of  urine  ranged  from  20  to  30  pints. 

1-5 


226  DIABETES    INSIPIDUS. 

toms  commenced  immediately  after  recovery  from  the  initial 
complaint. 

In  two  cases,  the  symptoms  commenced  immediately  after 
violent  muscular  effort.  One  was  a  boy  of  twelve,  who  strained 
himself  in  pushing  a  cart-wheel  sunk  in  the  mud.  After  a  few 
months,  the  symptoms  were  subdued  by  nitrate  of  potash ;  but 
some  months  later  a  relapse  occurred,  and  the  patient  died  sud- 
denly, from  taking,  as  is  alleged,  too  large  a  dose  of  the  nitrate 
(P.  Frank — cited  by  Romberg).  The  second  is  a  remarkable 
case,  related  by  Jarrold,  in  Duncan's  "Annals"  for  1801.  A  girl 
of  19,  when  going  down  a  flight  of  steps,  slipped ;  with  very- 
great  exertion  she  saved  herself  from  falling.  Immediately 
after  menorrhagia  began,  and  on  the  evening  of  the  same  day 
she  experienced  inordinate  thirst  and  profuse  diuresis.  She 
entered  the  Edinburgh  Infirmary,  under  Professor  Gregory, 
and  was  speedilj-  cured  of  the  hemorrhage  by  the  compound 
powder  of  alum.  The  urine  amounted  to  the  enormous  quan- 
tity of  50  lbs.  in  the  twenty-four  hours,  sometimes  even  to  60 
lbs.,  and  one  da,j  to  72  lbs. !  Under  the  influence  of  lime-water 
and  powdered  galls,  the  urine  was  gradually  reduced  to  between 
5  lbs.  and  10  lbs.  a  day.  She  left  the  hospital  otherwise  in  good 
health. 

Three  cases  were  attributed  to  hereditary  influence.  One  of 
these  w-as  a  man  in  good  health,  who  had  suffered  for  the  long 
period  of  fifty-nine  years  from  polyuria.  The  disorder  began  in 
infancy.  His  father,  two  brothers,  and  a  sister  had  suti'ered 
similarly.  Another  was  a  healthy  soldier  of  twenty-four,  who 
had  been  polyuric  for  four  years.  His  mother,  brothers,  and 
two  sisters  suffered  in  the  same  way.  The  third  was  a  young 
lady  of  nineteen,  mentioned  by  Trousseau  ("  Clinique  Medicale," 
t.  ii.  611),  whose  grandfather  was  affected  with  saccharine  dia- 
betes, and  uncle  with  Bright's  disease.  She  was  well-grown 
and  tolerably  healthy,  and  had  borne  her  complaint  for  six 
years.     All  these  cases  proved  incurable.^ 

Course  and  SYMPTOMb. — The  invasion  of  the  complaint  is 
often  quite  sudden.  Dr.  Bennett  relates  the  ease  of  a  woman, 
thirty-four  years  of  age,  who  went  to  her  work  one  morning  at 
six  o'clock  in  her  usual  health ;  at  eight  o'clock,  two  hours  after, 
she  was  suddenly  seized  wnth  intense  thirst  and  diuresis,  which 
became  persistent  from  that  time. 

In  several  instances  it  is  recorded  that  an  intercurrent  febrile 
or  inflammatory  disorder  temporarily  suspended  the  symptoms. 

1  Orsi  (Virch.  and  Hirsch.  Jahresb.,  ii.  p.  244,  1881)  reports  a  most  remark- 
able family  history.  In  a  family  of  nine,  consisting-  of  parents,  four  sons,  two 
daughters,  and  a  maternal  uncle,  no  less  than  six  suffered  from  Polyuria.  Weil 
(Virch.  Archiv,  Bd.  9.5)  gives  a  still  more  remarkable  history  of  a  family,  in 
which  no  less  than  twenty-two  members  were  the  subjects  of  Diabetes  Insipidus. 


COUKHK    AND    HYM  J"l'OMS  227 

III  one  case,  an  attack  of  acute  articular  rJicuniatisni  (treated 
with  nitrate  of  potash)  suspended  the  disease  permanently,  after 
it  had  existed  in  intensity  for  eighteen  years.  In  another  in- 
stance (a  girl  of  nineteen,  polyuric  from  infancy),  an  attack  of 
pleurisy  was  treated  by  a  blister,  which  suppurated  for  tliirty- 
five  days;  at  the  end  of  tliis  time,  both  the  pleurisy  and  the 
polyuria  disappeared  permanently.  In  a  third  case  (recorded 
by  Kiilz)  an  attack  of  varioloid  suspended  the  symptoms  tempo- 
rarily during  the  course  of  the  fever. 

The  quantity  of  urine  voided  by  persons  afflicted  with  insipid 
diabetes,  is  usually  considerably  greater  than  in  saccharine  dia- 
betes; 15,  30,  and  even  40  pints  are  frequently  mentioned  as  the 
daily  amount  of  urine.^  Its  specific  gravity  varies  from  a  little 
above  that  of  pure  water  to  1003  and  1007.  It  is  limpid  and 
colorless,  and  contains  but  a  feeble- proportion  of  solid  matters. 
The  total  quantity  of  urea  excreted  in  twenty-four  hours  is 
usually  greatly  increased.  In  many  cases  also  the  amount  of 
phosphates  is  much  in  excess  of  the  normal,^  but  the  proportion 
to  each  other  of  the  remaining  normal  ingredients  of  the  urine 
has  not  been  found  sensibly  altered.  The  only  abnormal  sub- 
stance that  has  hitherto  been  detected  is  inosite.  Inosite  in 
small  quantities  has  been  found  several  times ;  and  it  has  been 
suggested  that  the  presence  of  this  substance  in  the  urine  was 
characteristic  of  the  disease.  This  is,  however,  not  the  case. 
Inosite  has  been  found  repeatedly  in  D.  Mellitus  and  in  Albu- 
minuria. Probably,  as  Strauss  conceives,  the  appearance  of 
inosite  is  merely  a  coincidence  of  the  excessive  transudation 
of  watery  fluid  through  the  tissues  of  the  body;  for  he  found 
inosite  in  the  urine  of  three  healthy  persons  who,  for  the  purpose 
of  experiment,  had  drunk  in  the  course  of  a  day  a  large  quantity 
(10  litres)  of  water.^ 

The  thirst  is  generall}^  intense;  often  inextinguishable;  in 
several  cases  the  patients  are  stated  to  have  drunk  their  own 
urine.  When  the  quantity  of  drink  and  the  quantity  of  urine 
were  compared,  sometimes  the  one  and  sometimes  the  other 
showed  in  excess.  Careful  determinations  on  this  point  by 
Falck,  ITeuschler,  and  others,  indicate  that  if  fluids  be  allowed 
ad  libitum  the  urine  voided  is  about  the  same  quantity  as  the 
drink;  but  if  the  imbibition  of  fluids  be  compulsorily  dimin- 
ished, the  urine  is  not  diminished  in  the  same  proportion,  and 
dehydration  of  the  tissues  results. 

1  A  little  sjirl  of  ten,  under  my  care  at  the  Manchester  Infirmary,  passed 
rather  more  than  a  third  of  her  own  weight  of  urine  daily  for  some  weeks — and 
yet  continued  in  fair  health.     Her  weight  was  56  lbs. 

2  See  Dickinson,  loc.  cit.,  and  Ralfe, "Lancet,  i.,  1881.  This  phenomenon,  how- 
ever, is  hardly  sufficient  to  justify  the  term  Phosphatic  Diabetes,  as  introduced  bv 
Teissier. 

3  See  Gallois's  Thesis,  De  I'Inosurie,  Paris,  1864;  and  Strauss's  Thesis,  p.  25. 


228  DIABETES    INSIPIDUS, 

The  skill  is  generall}^  dry  and  harsh;  sometimes  it  preserves 
its  natural  moisture,  and  in  rare  examples  sweating  has  been 
observed,  ^  It  is  noteworthy  that  boils  and  carbuncles  are  rarely 
mentioned. 

Klilz  records  a  case  in  which  spontaneous  persistent  ptyalism 
(not  caused  by  mercury)  coexisted  with  D.  Insipidus  in  a  girl  of 
eighteen.  She  was  under  observation  for  about  four  months; 
and  voided  daily  from  12  to  18  ounces  of  saliva  and  200  to  260 
ounces  of  urine,  Kiilz  calls  attention  to  the  fact  that  ptyalism 
is  produced  in  dogs  and  rabbits  (according  to  the  experiments 
of  Eckhard,  Nollner,  and  himself)  by  puncture  of  the  floor  of 
the  fourth  ventricle,  showing  that  the  controlling  nerve-centre 
of  the  salivary  glands  lies  closely  adjacent  to  that  of  the  kidneys, 
and  supplying  the  physiological  key  to  the  coexistence  of  D. 
Insipidus  and  ptyalism.  Worm  Miiller  also  has  reported  a  case 
in  which  the  saliva  was  much  increased  in  quantity,^ 

The  state  of  the  general  health  varies  a  good  deal.  In  the 
greater  number  of  the  recorded  cases  fair  health  was  preserved 
— in  several  patients  the  health  was  perfect,  and  some  of  them 
became  fathers  and  mothers  of  families,  and  went  about  their 
usual  avocations  without  other  detriment  than  the  inconveni- 
ence of  a  constant  thirst  and  incessant  calls  to  void  urine.  A 
remarkable  example  of  this  kind  was  communicated  by  Mr. 
Maxwell  to  Dr.  Simmons  ("  Med.  Facts  and  Obs.,"  vol.  ii.  ^6).  A 
hale  farm  laborer,  aged  fifty-one,  who  habitually  performed  the 
severest  tasks,  thrashing,  mowing,  etc.,  like  his  fellow-workmen, 
had  been  polyuric  for  twenty-four  years.  The  disorder  came 
on  after  a  fit  of  ague.  The  patient  drank  daily,  summer  and 
winter,  from  32  to  36  pints  of  water,  and  voided  urine  in  pro- 
portion. Yet  he  slept  well  (except  that  he  frequently  awoke  to 
drink):  he  had  no  pain  or  ache  of  any  sort;  he  had  an  excellent 
appetite,  a  moist  skin,  and  perspired  freely  when  he  was  at 
work.  Dr.  Simmons  also  cites  the  case  of  a  woman  residing  in 
Paris,  who  had  been  polyuric  from  infancy.  In  due  time  she 
married  a  cobbler,  and  became  the  mother  of  eleven  children, 
of  whom,  however,  only  two  were  living  when  the  case  was  re- 
corded. Dr.  Willis  quotes  the  history  of  an  artisan,  aged  fifty- 
five,  who  entered  the  Hotel  Dieu,  of  Paris,  for  some  trifling 
bruise  of  the  knee,  from  which  he  speedily  recovered,  Fronpi 
the  age  of  five  years  he  had  suffered  from  a  constant  thirst, 
accompanied  with  a  commensurate  diuresis.  From  his  sixteenth 
year  he  had  drunk  on  an  average  two  bucketsful  of  water 
daily.  This  man  continued  in  good  health ;  he  was  the  father 
of  several  children,  and  experienced  no  inconvenience  from  his 
infirmity  beyond  what  was  inseparable  from  the  frequent  calls 

'  See  Yirch.  and  Hirsch.  Jahresber.,  1879,  ii.  p.  246. 


couk.se  and  symptoms.  229 

to  pass  water,  and  the  constant  necessity  for  drink.  In  a  boy  of 
ten,  under  my  care,  in  the  Manchester  Iniirmary,  who  had  been 
voidino;  about  fifteen  pints  of  urine  daily  for  several  months,  the 
general  health  and  nutrition  were  perfect.  ]^]xcepting  a  dry 
tongue  and  skin,  tliere  was  no  abnormal  condition  ajiart  from 
the  excessive  thirst  and  polyuria.  The  boy  was  active  and  in- 
telligent, and  he  ate  and  slept  well,  and  looked  rosy  and  plump. 

This  high  state  of  health  is  however  exceptional:  more  com- 
monly the  patients  are  very  decided  valetudinarians;  and  the 
s_ymptoms  from  which  they  suffer  bear  a  resemblance  to  those  of 
diabetes  mellitus,  though  rarely  exhibited  in  equal  severity. 
These  are  epigastric  and  lumbar  pains;  dry,  harsh,  hot  skin  ; 
painful  dryness  and  heat  of  the  mouth  and  fauces;  emaciation. 
Sometimes  the  appetite  is  voracious,  more  commonly  moderate 
or  indifferent.  The  temper  is  querulous;  the  mental  faculties 
enfeebled;  the  bodil}^  strength  diminished;  the  sexual  functions 
often  abolished.  The  face  is  subject  to  erythematous  conges- 
tion. Enforced  abstinence  from  fluids  aggravates  most  of  these 
symptoms:  the  body  then  becomes  unbearably  hot,  the  skin 
suffused,  a  sense  of  intolerable  sinking,  or  even  of  intense  pain, 
is  felt  in  the  pit  of  the  stomach,  and  the  intellect  becomes  con- 
fused. 

The  loss  of  rest,  the  tormenting  thirst,  the  mental  worry,  at 
lengtb  produce,  in  most  instances,  an  exhaustion  of  the  bodily 
vigor;  oedema  of  the  feet  often  appears  towards  the  last.  The 
disease  is,  however,  seldom  fatal  directly  by  its  own  virulence. 
More  frequently  the  patient  succumbs  to  some  concomitant 
disorder — phthisis,  pleuro-pneumonia,  or  organic  disease  of  the 
brain. 

In  some  cases  there  was  dislike  to  vegetable  aliments,  in 
others  to  animal  food.  The  cobbler's  wife,  before  alluded  to, 
was  very  sensitive  to  alcoholic  drinks;  a  single  glass  of  wine 
caused  uneasy  sensations  in  all  her  limbs,  and  a  sense  of  faint- 
ness.  In  other  instances  the  patients  drank  freely  of  wine  or 
beer,  as  their  condition  allowed.  In  a  man  observed  by  Trous- 
seau, there  was  a  remarkable  tolerance  of  alcoholic  stimulants. 
This  man  on  one  occasion  drank  a  litre  (a  pint  and  three- 
quarters)  of  brandy  in  two  hours;  and  while  in  hospital  he  im- 
bibed daily  a  similar  quantity  without  the  smallest  inconveni- 
ence. The  patient  related,  that  since  his  illness  began  he  had 
acquired  this  singular  immunity  from  the  causes  of  drunkenness. 
More  than  once  he  had  laid  wagers  to  drink  twenty  bottles  of 
wine  at  a  single  sitting,  and  had  won  his  wagers  without  the 
least  disturbance  of  the  nervous  system. 

Irritability  of  the  bladder,  with  excessively  frequent  micturi- 
tion, was  noted  in  several  instances. 

The    duration    of    the    complaint   is   exceedingly    uncertain. 


230  DIABETES    INSIPIDUS. 

The  traumatic  cases  generally  onlj^  lasted  a  few  weeks  or 
months:  on  the  other  hand,  one  of  the  congenital  cases  had 
endured  iifty-nine  years,  another  fifty  years,  at  the  date  of  the 
record. 

Out  of  seventy-seven  cases  collected,  sixteen  were  reported  as 
complete  recoveries;  fourteen  ended  fatally;  and  the  remaining 
forty-seven  were  still  in  progress  when  reported;  though,  in 
some  of  them,  considerable  amelioration  had  taken  place.  In 
the  sixteen  recoveries  the  duration  of  the  disease  was  mostly 
comparatively  short, — in  nine,  it  was  under  a  year;  in  one,  four 
years;  in  two,  eighteen  and  nineteen  years;  and  the  remainder 
"  some  "  years.  In  the  fourteen  fatal  cases,  the  duration  was 
still  shorter.  In  nine  of  them  it  was  under  a  year;  one  died 
in  the  short  space  of  seven  weeks;  two  more  in  two  months. 
The  other  live  survived  for  periods  varying  from  eighteen 
months  to  twenty  years. 

Of  forty-seven  cases  still  in  progress  when  reported,  the 
duration  of  the  disease  was  mentioned  in  thirty-iive  instances : 
Five  had  continued  for  a  year  or  under;  five,  for  between  one 
and  two  years;  twelve,  for  between  two  and  six  years;  six,  for 
between  six  and  twelve  years;  four,  for  between  twelve  and 
twenty-four  years;  and  four,  for  between  twenty-four  and  fifty- 
nine  years. 

Morbid  Anatomy. — The  condition  of  the  organs  after  death 
from  diabetes  insipidus,  has  only  been  ascertained  in  a  few  cases. 
I  have  collected  fourteen  post-m.ortem  examinations;  and  to  these 
I  add  one  performed  by  myself  In  three  of  these  cases  the 
lesions  found  presented  a  tolerably  close  similarity,  and  con- 
sisted of  an  atrophied  and  degenerated  condition  of  the  renal 
substance;  in  a  fourth,  the  glandular  tissue  of  the  organs  was 
entirely  wanting;  in  a  fifth,  multiple  abscesses  were  found  in 
the  kidneys;  in  my  own  case,  and  in  three  others,  the  kidneys 
were  simply  hypersemic  and  somewhat  enlarged,  and  a  tumor 
was  found  in  the  brain. ^  In  two  cases,  fatty  degeneration  of  the 
nervous  tissue  of  the  walls  of  the  fourth  ventricle  was  found. 

As  these  cases  are  so  few  in  number,  I  shall  describe  them 
more  fully. 

Case  1.  (Dr.  Eade — Beale's  "Archives,"  1861,  p.  8.)— A  man,  aged 
65,  had  suffered  from  jaundice  and  neuralgia  ;  he  succumbed  in  eighteen 
months  to  the  continual  diuresis,  and  the  urgent  and  incessant  calls  to 
void  urine.  The  quantity  of  urine  varied  from  three  to  six  pints  ;  spe- 
cific gravity  never  exceeded  1008 ;  it  was  free  from  sugar,  albumen,  or 
other  morbid  ingredient.     The  autopsy  revealed  the  following :  "  The 

1  In  an  appendix  to  the  present  chapter  reference  is  made  to  some  cases  of 
polyuria  (with  records  of  post-mortem  examinations),  in  which  a  minute  quantity 
of  sugar  existed  temporarily  in  the  urine. 


ILLUSTRATIVE    CASES.  231 

infundibula  and  pelvis  of  both  kidneys  were  greatly  dilated,  and  the 
state  of  sacculated  kidney  was  evidently  in  process  of  establishment. 
Left  kidney  of  natural  size.  Kight,  one-half  larger,  and  of  darker  color. 
Both  showed  depressions  along  the  surface,  marking  the  interlobular 
portions.  Previous  to  section,  the  cones  could  be  distinctly  felt  as  much 
denser  than  the  interpyraraidal  portions,  giving  indeed  the  sensation  of 
so  many  little  tumors  or  nodules.  On  section,  both  were  seen  to  be  pale 
and  flaccid,  and  evidently  undergoing  a  gradual  process  of  absorption." 
The  bladder  was  somewhat  large  and  thickened ;  the  ureters  dilated. 
The  thoracic  and  the  other  abdominal  organs  were  not  diseased. 

Case  2.  (Dr.  Eade— Beale's  "Archives,"  1862,  p.  128.)— A  man,  aged 
62,  had  experienced  excessive  thirst  and  diuresis  for  twenty  years. 
Health  fair,  until  two  years  before  death,  when  it  began  to  fail,  and  for 
the  last  nine  months  he  was  unable  to  work.  The  quantity  of  urine 
often  amounted  to  between  fourteen  and  sixteen  pints,  and  had  never 
contained  sugar  or  albumen.  There  was  little  pain  beyond  a  sense  of 
weariness.  The  bowels  were  constipated,  and  the  stomach  very  irritable 
with  frequent  vomiting.  At  length  the  bladder  became  unable  to  expel 
its  contents,  and  a  typhoid  state  supervened  ;  the  stomach  rejected  every- 
thing, and  he  died  exhausted. 

Autopsy. — Both  kidneys  were  diminished  in  size,  deeply  lobed  on  the 
surface,  and  very  dense  to  the  feel  in  the  position  of  the  cones.  On 
section,  they  were  seen  to  be  greatly  wasted.  The  cortical  portions  very 
thin,  and  scarcely  to  be  distinguished  from  the  pyramidal.  The  cones 
were  nearly  absent,  or  rather  were  converted  into  dense  fibrous  tissue, 
containing  many  large  cystiform  spaces.  The  mucous  membrane  of  the 
pelvis  was  thickened,  fibrous-looking,  and  darkly  congested.  The  pelvic 
cavities  considerably  enlarged.  Ureters  a  little  dilated.  On  micro- 
scopical examination  (by  Dr.  Beale),  many  of  the  tubes  were  found 
narrow  and  much  wasted,  while  others  were  twice  their  natural  diame- 
ters. The  walls  of  the  tubes  were  firm  and  thick.  The  capillary  vessels 
everywhere  were  surrounded  by  a  considerable  quantity  of  fibrous  mate- 
rial with  numerous  nuclei.  The  Malpighian  bodies  were,  for  the  most 
part,  smaller  than  in  health.  The  epithelial  cells  were  also  smaller,  as 
well  as  more  numerous  than  in  health,  and  the  tubes  appeared  to  be  dis- 
tended in  many  places  by  their  accumulation.  The  suprarenal  capsules 
were  greatly  diseased,  and  converted  into  flaccid  cysts.  The  bladder 
was  enlarged,  and  its  walls  thin  and  pale.  The  other  abdominal  organs 
were  healthy,  except  perhaps  the  liver,  which  was  intensely  congested. 
In  neither  case  does  the  brain  appear  to  have  been  examined. 

Case  3.  (NeufFer — cited  in  Magnant's  Thesis.) — A  man,  aged  28. 
The  disease  came  on  after  a  drunken  bout.  There  was  intense  thirst ; 
the  urine  amounted  to  thirteen  or  fourteen  pints  a  day  ;  specific  gravity 
1001  to  1002 ;  without  trace  of  albumen  or  sugar.  He  emaciated 
rapidly  ;  had  pain  in  the  epigastrium ;  at  length  frequent  vomiting  ; 
itching  of  the  skin,  which  was  dry;  enfeebled  vision.  He  died  in 
about  two  months. 

Autopsy. — The  gastric  mucous  membrane  was  pale  and  swollen;  the 
kidneys  Avere  notably  diminished  in  size,  pale,  auremic  ;  the  epithelium 


232  DIABETES    INSIPIDUS. 

of  the  tubes  fatty ;  bladder  contracted ;    mucous   membrane   a   little 
tumefied  ;  other  organs  healthy. 

Case  4.  (Dr.  Strange— Beale's  "Archives,"  1862,  p.  276.)— The  patient 
was  a  farm  laborer,  aged  18,  who  presented  the  appearance  of  a  moder- 
ately stout  lad  of  15.  He  was  admitted  into  the  Worcester  Infirmary 
on  October  19,  1861.  The  skin  and  tongue  were  natural,  and  the  face 
ruddy;  appetite  normal;  thirst  constantly  excessive ;  bowels  generally 
relaxed.  The  urine  amounted  to  about  twelve  pints  in  the  twenty-four 
hours ;  its  specific  gravity  was  1007 ;  it  contained  neither  sugar  nor 
albumen.  All  the  history  obtainable  was,  that  the  patient  had  been  a 
delicate  and  backward  boy ;  that  he  had  had  this  diuresis  for  a  number 
of  years,  and  that  the  medical  attendant  had  always  affirmed  that  the 
urine  did  not  contain  sugar. 

Dr.  Strange,  being  desirous  to  ascertain  whether  the  diuresis  was  kept 
up  by  the  excessive  imbibition  of  fluids  (in  accordance  with  the  theory 
of  Prof  Bennett  and  others),  restricted  the  patient  to  a  more  moderate 
allowance  of  fluids.  A  warm  bath  was  administered  twice  a  week. 
Four  days  after  admission  (October  23),  the  urine  measured  nine  pints  ; 
its  specific  gravity  was  1006.  On  the  26th  the  bowels  were  much  re- 
laxed ;  urine  five  pints.  On  the  28th,  a  phosphoric  acid  mixture  which 
he  had  been  previously  taking  was  omitted,  and  Mist.  cret.  co.  given 
instead.  On  this  day  the  patient  complained  for  the  first  time  of  head- 
ache, with  weakness  and  loss  of  appetite ;  there  were  also  some  febrile 
symptoms.  On  the  29th,  the  bowels  being  still  relaxed,  five  minims  of 
tinct.  opii,  and  half  a  drachm  of  tinct.  catechu  were  added  to  the  mix- 
ture. On  the  30th  he  became  drowsy,  with  pain  at  the  back  of  the 
head;  the  diarrhoea  continued,  with  vomiting.  Effervescing  draughts, 
with  nitric  ether,  were  now  administered  in  lieu  of  the  previous  medi- 
cines ;  half  an  ounce  of  brandy  was  given  three  times  a  day,  and  cold 
applied  to  the  head.  On  November  2d,  the  drowsiness  and  sickness  had 
abated ;  the  bowels  were  confined ;  the  urine  three  and  a  half  pints, 
specific  gravity  1004.  The  brandy  was  omitted,  and  half  an  ounce  of 
castor  oil  administered.  As  it  now  appeared  that  restricting  the  patient 
in  his  drink  had  resulted  in  mischief,  he  Avas  allowed  to  take  as  much 
water  or  barley-water  as  he  pleased.  On  November  4th,  in  the  morning, 
he  was  again  drowsy ;  in  the  evening  he  was  seized  with  convulsions, 
and  shortly  afterwards  he  became  comatose  and  insensible,  with  dilated 
pupils  and  stertorous  bi^eathing.  He  was  bled  to  §x,  and  much  relieved 
thereby.  The  coma  ceased,  and  consciousness  and  speech  returned  in  a 
quarter  of  an  hour.  Mustard  was  applied  to  the  feet,  and  a  draught 
containing  tinct.  canthar.  and  sp.  seth.  nit.  in  camphor  water  was  given 
every  third  hour,  with  a  view  of  restoring  the  accustomed  diuresis.  On 
the  morning  of  the  5th  he  was  conscious,  and  still  had  some  headache. 
The  diuretic  mixture  was  continued,  and  a  black  draught  administered 
immediately.  On  the  6th  he  was  again  found  in  a  semi-comatose  state, 
the  pupils  were  dilated,  and  there  was  stertor,  with  sighing  respiration. 
Six  leeches  were  applied  to  the  temples,  mustard  to  the  feet,  and  cold  to 
the  head.     Then  coma  became  more  profound,  and  he  died  at  9  p.m. 

Autopsy. — The  kidneys  were  found  to  be  reduced  to  mere  sacs,  of  from 
twice  to  thrice  the  extent  of  the  healthy  kidney.     There  was  a  complete 


ILLUSTKATIVB    CASKS.  233 

absence  of  all  proper  parenchymatous  8ul)8ttuic(!,  both  tuhiihir  and  cor- 
tical ;  the  sacs  being  divided  into  a  nurrd)er  of  cells  by  the  intertuhuiar 
septa  which  occur  in  the  fo.^tal  state.  The  walls  and  septa  were  formed 
of  strong  fibrous  tissue,  lined  with  what  appeared  rather  serous  than 
mucous  membrane,  and  the  cavity  and  ureters  contained  a  small  quan- 
tity of  the  same  urinous  fluid  which  had  been  passed  during  life.  The 
ureters  were  so  much  dilated  that  that  on  the  right  side  was  at  first  mis- 
taken for  the  ascending  colon.  The  circumference  of  the  ureter  varied 
from  three  to  four  and  a  half  inches.  The  kidney  and  ureter  of  either 
side  were  almost  precisely  in  the  same  condition.  The  urine  in  the 
ureters  and  sacs  was  tested  for  urea  by  evaporation  and  nitric  acid, 
without  result.  On  closer  examination  no  proper  kidney  substance 
could  be  discovered,  nor  did  it  appear  that  there  ever  had  been  any 
tubular  or  cortical  portions;  here  and  there  were  a  few  hard  cartilagin- 
ous masses  of  very  small  size,  closely  adherent  to  the  membrane  forming 
the  sac.  The  other  abdominal  and  the  thoracic  organs  were  healthy. 
The  brain  was  not  examined. 

Case  5.— On  the  29th  of  May,  1862,  I  saw,  with  Mr.  J.  Smith,  of 
Stretford  Road,  a  youth  of  16  years  of  age,  who  was  passing  a  large 
quantity  of  a  watery  urine.  He  was  moderately  well-grown,  exceedingly 
emaciated,  weighing  only  78  pounds.  Pulse  127  ;  tongue  glazed,  red  in 
the  centre,  and  covered  with  a  yellowish-brown  fur  at  the  sides.  The 
skin  was  dry  and  harsh.  The  patient  was  troubled  with  intense  and 
incessant  thirst,  and  voided  from  nine  to  twelve  pints  of  urine  daily. 
The  appetite  was  bad.  Neither  the  head  nor  chest  was  the  seat  of  any 
subjective  symptom. 

He  gave  the  following  account  of  himself:  Previous  to  his  present 
illness  he  was  occupied  as  a  clerk  in  a  warehouse,  and  had  enjoyed  unin- 
terrupted health  until  three  months  ago.  About  that  time  he  noticed 
that  he  was  getting  thinner  and  w^eaker,  that  he  drank  a  great  deal,  and 
never  perspired.  These  symptoms  had  undergone  a  gradual  and  steady 
increase,  and  a  fortnight  ago  had  sustained  an  alarming  aggravation. 
The  patient  could,  nevertheless,  still  go  about,  and  even  take  the  air  for 
short  periods.  He  suffered  no  pain  in  any  part,  but  he  slept  badly,  and 
passed  restless  nights.  The  appetite  had  been  indifferent  from  the  very 
beginning,  and  it  was  now  altogether  lost.  The  bowels  were  moved 
almost  daily,  but  there  was  a  tendency  to  constipation.  Dyspeptic 
symptoms — heaviness  after  food,  flatulence,  and  occasional  vomiting — 
bad  been  noted  from  the  commencement  of  the  illness,  but  they  did  not 
attain  a  great  severity  at  any  time. 

In  searching  back  among  the  patient's  antecedents  for  any  determin- 
ing cause,  no  fact  of  moment  was  elicited.  The  lad  had  been  living  in 
comfort,  well-clad,  w^ell-fed,  and  well-housed,  with  his  grown-up  sisters. 
No  tuberculous  or  other  family  taint  could  be  traced.  The  case  had 
been  treated  wdth  morphia,  bismuth,  and  permanganate  of  potash,  but 
with  no  result  beyond  a  palliation  of  the  dyspeptic  symptoms. 

The  urine  of  the  twenty-four  hours  was  carefully  collected  and 
measured  on  six  several  occasions,  and  portions  sent  to  me  for  examina- 
tion. The  characters  of  it  were  constant ;  it  was  pale  like  water,  and 
the  specific  gravity  varied   from   1002.7  to   1004.     The  quantity  was' 


234  DIABETES    INSIPIDUS, 

between  uiiie  and  ten  pints  at  the  time  of  my  visit.  It  afterwards  in- 
creased to  fourteen  pints  daily.  There  was  neither  albumen  nor  sugar 
in  it,  and  its  reaction  was  faintly  acid.  The  quantity  drank  was  found, 
on  exact  measurement,  to  be  almost  precisely  equal  to  the  quantity  of 
urine.  The  amount  of  urea  varied  from  0.4  to  0.55  per  cent.,  and  from 
394  to  505  grains  in  the  twenty-four  hours.  This  was  an  enormous  quan- 
tity for  the  weight  of  the  body.  According  to  the  mean  results  tabu- 
lated by  Dr.  Parkes,  the  daily  secretion  for  his  weight  of  78  pounds 
should  only  have  been  275  grains. 

The  patient  continued  without  much  change  beyond  a  progressive 
increase  of  debility  and  loss  of  flesh,  drinking  enormously,  and  voiding 
corresponding  quantities  of  urine,  until  July  5th,  when  he  was  suddenly 
seized  with  convulsions  and  insensibility.  After  the  convulsions  had 
ceased,  he  began  to  recover  some  degree  of  consciousness,  and  passed  into 
a  semi-comatose  condition,  which  persisted  for  three  days,  and  then 
passed  away.  During  the  period  of  unconsciousness  the  diuresis  dimin- 
ished notably;  but  it  returned  immediately  afterwards,  and  the  patient 
continued  very  much  as  he  was  before  the  seizure,  for  a  period  of  ten 
days,  when  he  was  again  taken  with  convulsions  and  insensibility,  and 
died  on  the  morning  of  July  18th. 

Autopsy. — Thirty  hours  after  death.  The  body  was  emaciated  to  the 
last  degree ;  signs  of  incipient  putrefaction  appeared  on  the  abdomen, 
the  weather  being  warm. 

Chest. — The  heart  was  healthy,  but  very  small ;  the  lungs  were  stuffed 
with  crude  tubercle  throughout  their  upper  lobes,  and  several  small 
vomicae  lay  scattered  through  them. 

Abdomen. — Five  tuberculous  ulcers  were  discovered  in  the  small  intes- 
tines; some  of  them  had  penetrated  the  mucous  and  muscular  coats, 
and  seemed  ready  to  break  through  the  peritoneum.  There  was  no 
tubercular  deposit  in  the  peritoneum  generally,  nor  any  in  the  liver  or 
spleen. 

The  kidneys  were  voluminous,  smooth,  flaccid,  and  the  two  together 
weighed  eight  ounces.  On  section  they  showed  no  disproportion  between 
the  pyramidal  and  cortical  portions,  nor  any  other  morbid  change. 
Examined  microscopically,  the  tubes  and  cells  appeared  normal. 

Mead. — About  two  ounces  of  clear  serum  escaped  from  the  arachnoid 
sac.  The  meninges  were  free  from  tubercle,  and  quite  natural.  The 
ventricles  were  greatly  distended,  and  contained  six  ounces  of  clear 
serum  ;  their  parietes  were  macerated,  and  gave  way  with  the  slightest 
traction. 

A  nodule  of  yellow  tubercle,  of  the  size  of  a  hazel-nut,  lay  embedded 
in  the  left  hemisphere,  in  the  border  of  the  longitudinal  fissure,  midway 
between  its  extremities,  and  cropping  out  on  the  surface.  Another 
nodule,  as  large  as  a  garden-bean,  was  found  in  the  posterior  border  of 
the  right  half  of  the  cerebellum.  An  undue  vascularity  prevailed  at  a 
few  spots  of  the  surface  of  the  encephalon.  Apart  from  what  has  been 
related,  the  brain  substance  was  healthy  and  of  firm  consistence.  The 
floor  of  the  fourth  ventricle  was  especially  examined  ;  it  was  pale  and 
natural,  with  no  tubercular  mass  in  its  immediate  vicinity. 

Case  6.  (Mascarel— "Gaz.  d.  Hop.,"  February  23, 1863.)— The  patient 
was  a  man,  aged  50,  pale  and  thin,  without  fever,  but  a  devouring  thirst. 


ILLUSTRATIVE    CASKS.  235 

and  a  red  tongue ;  appetite  good,  hut  nc)t  voracioiiH.  lie  drank  daily 
from  eight  to  ten  pints  of  water,  and  voided  urine  prfjportionaily.  The 
disease  had  existed  eight  months.  Seven  days  after  entering  the  hospital, 
he  became  feverish,  at  first  ordy  in  the  night,  then  continuously,  with 
nausea,  and  epigastric  tenderness.  Thirst  was  intense,  l)ut  there  was  no 
api)etite.  Not  the  least  trace  of  sugar  or  albumen  existed  in  the  urine. 
The  urine  showed,  after  the  fever  became  persistent,  on  cooling,  a  slight 
yellowish-white  deposit,  not  mucous,  but  as  if  purulent.  This  last  char- 
acter was  only  noticed  two  days  before  death. 

Autopsy. — The  left  kidney  was  more  voluminous  than  the  right,  and 
eight  to  ten  little  abscesses,  varying  from  the  size  of  a  pin's  head  to  a 
small  filbert,  were  found  in  the  cortical  part.  The  smaller  abscesses 
contained  almost  concrete  pus,  and  the  larger  ones  fluid  pus,  without 
any  tubercle.  The  infundibula  were  filled  with  a  creamy  fluid.  AIJ 
the  abscesses  were  near  to  and  reached  the  surface. 

The  right  kidney  was  of  natural  size,  hypcra^mic  and  free  from  dis- 
seminated abscesses,  but  a  lactescent  fluid  could  be  squeezed  from  the 
pyramidal  portions. 

The  brain  was  not  examined. 

Case  7.  ("Revue  d.  Hopitaux,"  1861.) — A  man,  set.  35,  who  had  had 
saccharine  urine  five  years  before,  was  passing  daily  six  to  seven  litres 
of  urine,  sp.  gr.  1001-7,  not  containing  either  albumen  or  sugar.  The 
patient  was  suffering  from  phthisis.  Being  seized  with  acute  pulmonary 
symptoms,  the  urine  fell  to  a  small  quantity ;  a  purpuric  eruption  came 
out  on  the  skin,  and  death  took  place  fourteen  days  after,  without 
cerebral  complications. 

Autopsy. — The  walls  of  the  fourth  ventricle  were  more  vascular  than 
usual,  and  some  tawny  spots  were  seen  disseminated  on  the  surface.  On 
making  transverse  sections  of  the  spots,  Luys  discovered  with  the  micro- 
scope extensive  fatty  degeneration  of  the  nerve  cells. 

Cases  8  and  9.  (Kien — "Gaz.  Hebd.,"  1866.) — In  one  case  Kien  found 
great  vascularity  of  the  kidneys.  In  the  walls  of  the  fourth  ventricle, 
scattered  yellow  spots  were  found,  which  exhibited  under  the  microscope 
abundant  evidence  of  fatty  degeneration  of  the  nerve  elements. 

In  his  second  case,  no  changes  were  found  in  the  kidneys — neither 
with  the  naked  eye  nor  with  the  microscope,  beyond  congestion  of  the 
Malpighian  bodies.     Nothing  was  found  in  the  medulla  oblongata. 

Case  10.  (Reported  by  Mosler  in  Virchow's  "  Archiv,"  43,  225.) — The 
patient  was  a  girl  of  22,  who  had  for  many  years  been  suffering  from 
symptoms  of  tumor  of  the  brain.  In  the  later  years  of  her  life_  she 
was,  in  addition,  suffering  from  symptoms  of  diabetes  insipidus.  After 
death,  a  tumor  as  large  as  a  walnut,  of  a  fibro-plastic  nature  (Glio- 
sarcoma  of  Virchow),  was  found  attached  to  the  floor  of  the  fourth  ven- 
tricle, and  filling  the  entire  cavity. 

Case  11.  (Dickinson  on  "  Diab.,"  p.  184.) — A  child  of  5  had  symptoms 
of  D.  insip.  for  about  a  year.  She  died  with  symptoms  of  tubercular 
meningitis.     Miliary  tubercles  and  thickening  were  found  at  the  base  of 


236  DIABETES    INSIPIDUS. 

the  brain  near  (but  not  in)  the  fourth  ventricle,  and  on  the  upper  sur- 
face of  the  cerebellum  ;  no  bulky  masses  of  tubercle  were  found. 

Case  12.  (Dickinson  on  "  Diab.,"  p.  223.) — A  man,  set.  60,  had  suffered 
from  diabetes  insipidus  for  fifteen  months,  and  had  been  ailing  for  two 
months  before  the  polyuria  was  noticed.  Post-mortem  there  was  found 
malignant  disease  of  the  liver  and  post-peritoneal  glands,  which  had 
involved  and  partially  destroyed  the  solar  plexus.  The  kidneys  were  of 
normal  size,  but  minutely  injected.  Microscopically  there  was  found 
some  excessive  growth  of  the  tubular  epithelium. 

Case  13.  (Ralfe,  "  Lancet,"  1881,  I.  p.  406.)— A  man,  set.  24,  with  a 
syphilitic  history,  had  suffered  from  polyuria  with  increase  in  the  amount 
of  phosphates  excreted.  Post-mortem  there  was  found  a  gumma  about 
the  size  of  a  small  hazel-nut,  situated  under  the  floor  of  the  third  ven- 
tricle in  the  middle  line.  It  was  surrounded  by  some  softening  of  the 
cerebral  substance. 

Case  14.  (Haas,  "  Prager-Vierteljahresch.,"  1875,  Bd.  127,  p.  12.)— A 
woman,  get.  23,  suffered  from  polyuria,  associated  with  almost  complete 
blindness  and  tuberculosis.  The  urine  passed  varied  from  five  to  ten 
litres  a  day,  and  occasionally  contained  a  little  albumen.  There  was 
found  post-mortem  tuberculosis  of  the  lungs  and  intestines.  The  optic 
nerves  were  atrophied,  but  no  change  of  importance  was  found  in  the 
brain.  The  kidneys  were  not  enlarged,  but  were  congested.  The  liver 
was  enlarged  and  hypersemic. 

Case  15.  (Fazio— see  "Lond.  Med.  Pvecord,"  1880,  p.  138.)— A  woman, 
aged  21,  had  suffered  for  three  years  from  excessive  thirst  and  polyuria, 
with  pains  in  the  head.  Dimness  of  vision  was  noticed,  but  no  ophthal- 
moscopic examination  was  made.  At  the  autopsy  a  sarcomatous  tumor 
was  found  in  the  region  of  the  sella  turcica,  causing  pressure  on  the 
brain  substance  in  the  neighborhood. 

I^ature  of  Diabetes  Insipidus. — A  review  of  the  post-mortem 
examinations  just  recorded,  is  suflBcient  to  show  that  the  initial 
disorder  in  diabetes  insipidus  must  be  looked  for  elsewhere  than 
in  the  kidneys.  The  diverse  organic  alterations  found  in  the 
kidneys  by  Eade,  N^eutFer,  and  Mascarel,  were  evidently  second- 
ary, and  produced  by  the  irritation  of  the  frequent  micturition 
and  excessive  and  long-continued  diuresis.  Similar  alterations 
are  found  in  the  kidneys  of  persons  dying  of  long-standing  sac- 
charine diabetes.  The  case  of  Dr.  Strange  is  certainly  very 
puzzling:  one  can  only  conceive  a  teleological  reason  for  the 
diuresis,  namely,  the  absolute  necessity  for  an  immense  transu- 
dation of  watery  fluid  to  make  up  for  tlie  imperfection  of  the 
glandular  apparatus. 

^OY  can  the  disease  be  regarded  merely  as  excessive  thirst  and 
a  vicious  habit  of  profuse  potation.  It  has  been  almost  invari- 
ably found  that  an  enforced  diminution  of  liquids  fails  to  arrest 


NATURE.  2'J7 

the  diuresis,  except  purtially.  The  oh.servutioTis  of  Kalck,  Xeu- 
scliler,  and  ISTeuffer,  agree  perfectly  in  this:  that  when  the  sup- 
ply of  water  hy  the  iriouth  is  dirniniKluMl,  the  quantity  of  urine 
notable  exceeds  the  ingoing  w^ater,  and  thereby  occasions  dehy- 
dration of  tlie  tissues,  with  an  intolerable  aggravation  of  tlie 
symptoms. 

It  may  be  regarded  as  prol)able  tluit  the  rimnedlate  anatomical 
cause  of  polyuria  is  a  dilation  of  the  renal  capillaries,  whereby 
their  walls  are  thinned  and  rendered  favorable  to  increased 
transudation  of  watery  fluid  from  the  blood.  But  how  is  this 
brought  about  ?  It  is  now  generally  believed  that  the  minute 
bloodvessels  possess  in  their  circular  and  longitudinal  muscular 
coats  a  provision  for  an  active  expansion  as  well  as  an  active 
constriction  of  their  calibre.^  This  provision  is  under  the  con- 
trol of  the  sympathetic  branches  of  nerves  (nervi  vasi-motores), 
and  serves  to  maintain  the  aqueousness  of  the  blood  within 
certain  limits  of  health.  When  the  tissues  and  blood  are  over- 
charged with  w^ater,  the  renal  vessels  expand,  and  permit  a  copi- 
ous transudation  of  an  aqueous  urine;  when,  on  the  other  hand, 
the  system  is  undercharged  with  water,  they  contract,  and  thereby 
restrict  the  urinary  transudation.  In  diabetes  insipidus  this 
endowment  seems  greatly  impaired;  the  renal  capillaries  appear 
to  resemble  the  iris  in  glaucoma,  which  remains  in  a  motionless, 
semi-dilated  state,  and  neither  contracts  witli  light  nor  dilates 
with  belladonna.  In  polyuric  subjects  the  contractile  power  of 
the  renal  vessels  is  apparently  paralyzed;  and  the  power  of  regu- 
lating the  urinary  flow  consequently  lost.  If  a  healthy  person 
imbibe  an  excessive  amount  of  w^ater,  he  rapidly  gets  rid  of  the 
overplus  by  a  sudden  and  copious  diuresis,  and  then  the  secre- 
tion falls  quickly  to  its  ordinary  rate :  but  a  polyuric  subject, 
under  similar  conditions,  shows  very  little  immediate  increase  of 
urine,  but  a  steady,  persistent,  though  less  intense,  augmenta- 
tion, lasting  many  hours,  and  which  is  not  succeeded  by  a  fall  to 
the  ordinary  standard.  On  the  other  hand,  if  a  healthy  person 
imbibe  a  lessened  quantity  of  w^ater,  the  discharge  of  urine  falls 
in  proportion:  whereas  the  polyuric,  under  the  same  circum- 
stances, show^s  no  such  adaptation  ;  he  still  continues  to  discharge 
an  undue  amount  of  urine,  which  necessitates  constant  imbibi- 
tion of  new"  supplies  of  water  to  prevent  dehydration  of  the 
tissues. 

On  this  view,  the  primary  cause  of  diabetes  insipidus  must  be 
looked  for  in  some  other  parts  than  in  the  kidneys;  namely,  in 
some  part  of  the  chain  of  sympathetic  nerves  which  controls  the 

^  For  a  demonstration  of  the  anatomical  possibility^  of  this  endowment  I  must 
refer  to  Schiti''s  ingenious  researches.  See  his  "  Untersuchungen  iiber  die  Zucker- 
bildung  in  der  Leber,"  p.  92.     Wiirtzburg,  1859. 


238  DIABETES    INSIPIDUS. 

action  of  the  contractile  tissues  of  tlie  renal  vessels.  This  chain 
extends  from  the  kidney's  to  the  abdominal  ganglia,  thence  to 
the  spinal  cord  and  the  Hoor  of  the  fourth  ventricle,  where  the 
sympathetic  s^^stem  seems  to  have  its  centre.  From  above,  this 
centre  receives  impressions  from  the  encephalon. 

This  theory  seems  conformable  both  to  experiment  and  to  clini- 
cal facts.  Bernard  found  that  by  puncturing  a  certain  spot  in 
the  floor  of  the  fourth  ventricle,  an  augmented  secretion  could 
be  produced  of  a  watery  urine,  containing  neither  sugar  nor 
albumen.  A  large  proportion  of  the  cases  of  diabetes  insipidus 
followed  injuries  to  the  nervous  centres,  or  were  evidently  de- 
pendent on  some  derangement  of  the  nervous  system.  In  six 
cases,  palpable  disease  of  the  brain  was  found  after  death,  while 
the  kidneys  were  healthy. 

Flatten  ("Arch.  f.  Psychiatrie,"  XIII.  p.  671,  1882}  has  recorded  a 
case  which  assists  to  localize  the  "poly uric"  centre.  A  patient,  after  a 
blow  on  the  head,  was  attacked  by  diabetes  insipidus.  There  were  also 
certain  permanent  symptoms  of  the  cerebral  disturbance.  Thus,  there 
was  paralysis  of  the  left  sixth  nerve  and  weakness  of  the  right  sixth, 
with  slight  deafness  on  the  left  side.  The  probable  diagnosis  was  hemor- 
rhagic softening  near  the  centres  for  the  sixth  nerves.  Flatten  calls 
attention  to  two  other  cases,  one  reported  by  Gayet  ( "  Gazette  Hebdo- 
mad.," No.  17,  1876),  in  which  paralysis  of  the  right  sixth  nerve  was 
accompanied  by  diabetes  insipidus;  and  another,  by  Kamutz  ("Arch, 
f.  Heilkunde,"  1873),  in  which  an  injury  to  the  head  was  followed  by 
paralysis  of  the  right  sixth  nerve  and  diabetes  mellitus. 

It  is,  perhaps,  worthy  of  remark  in  this  connection  that  puncture  of 
the  floor  of  the  fourth  ventricle,  near  the  nucleus  of  the  trigeminus,  has 
produced  increased  flow  of  saliva,  while  in  two  cases  (Kiilz  and  Worm 
Miiller)  salivation  was  observed  in  diabetes  insipidus. 

In  other  cases,  it  is  probable  that  the  sympathetic  in  the  ab- 
domen was  the  point  originally  injured.^  Among  such  may  be 
classed  those  arising  from  drinking  cold  fluids  while  the  body 
was  heated,  and  perhaps  also  those  following  alcoholic  excesses. 

The  influence  of  a  lesion  of  the  vagus  in  producing  the  disorder  is 
doubtful.  Dr.  Ralfe  ("  Lancet,"  1876, 1,  p.  308 )  has  recorded  two  cases 
of  aortic  aneurism  accompanied  by  diabetes  insipidus,  and  he  was  in- 
clined to  attribute  the  latter  symptom  to  pressure  on  the  vagus  in  the 

'  In  reference  to  this  point,  see  two  papers  by  Eckhardt  and  Knoll,  in  Eck- 
hardt's  Beitrage,  VI.  Heft  i. — also  Merbach's  paper  (Kiichenmeister's  Zeitsch., 
1865,  p.  10).  Probably  the  case  related  by  Professor  Houghton  was  of  this  character. 
This  was  a  woman  who  died  with  symptoms  of  D.  Insipidus,  together  with  dis- 
tention of  the  abdomen  from  fceal  accumulation  caused  by  a  viterine  tumor  press- 
ing on  the  rectum.  The  mesenteric  glands  connected  with  the  colon  were  enlarged 
and  indurated.  The  symptoms  had  lasted  nine  years.  Dublin  Quarterly,  Nov. 
1863.     See  Dr.  Dickinson's  case  mentioned  on  p.  235. 


DIAGNOSIS,    rilOGNOSlH,    TREATMENT.  239 

chest,  on  the  ground  that  Bernard  produced  jxjJyuria  by  irritating  the 
vagus.     Further  observations,  however,  are  required  to  support  this  view. 

A  ibiiture  of  the  disease  favorable  to  the  tljcory  of  its  nervous 
origin,  is  its  occasional  sudden  onset  after  events  whicli  do  not 
directly  implicate  the  urinary  organs;  and  its  equally  sudden 
subsidence  when  a  strong  impression  is  made  on  the  system  by 
an  intercurrent  inflammation.  The  total  and  unexpected  dis- 
appearance of  the  disease,  after  continuing  man}'  months  or 
years,  is  more  in  accordance  with  the  habit  of  neuroses  or  ner- 
vous diseases  than  of  any  other  class  of  maladies. 

The  Diagnosis  of  diabetes  insipidus  lies  on  the  surface.  A 
permanent  increase  of  the  urine,  without  sugar  or  alijumen, 
sufHces  at  once  to  define  and  to  identify  it.  But  it  is  evident 
from  the  facts  and  considerations  before  adduced,  that  to  gain  a 
useful  clew  for  treatment,  we  must  attain  to  more  precise  notions 
as  to  the  part  originally  affected — whether  brain,  or  cord,  or 
abdominal  ganglia,  and  also  as  to  the  nature  of  the  lesion  in  the 
affected  part. 

The  Prognosis  is,  speaking  generally,  less  serious  than  in 
saccharine  diabetes;  nevertheless,  insipid  diabetes  is  a  very  un- 
manageable complaint;  it  generally  resists  treatment,  and  not 
unfrequently  runs  a  fatal  course.  The  gravity  of  the  prognosis 
in  a  particular  case  depends  on  the  severity  of  the  general  symp- 
toms, and  on  the  presence  or  absence  of  complications.  The 
cases  which  affect  the  general  health  the  least,  though  mostly 
proving  incurable,  appear  to  be  those  which  arise  after  inflam- 
matory complaints,  after  mental  emotion,  cerebral  injuries,  and 
those  which  arise  early  in  life  without  an}'  known  cause.  On 
the  other  hand,  those  which  depend  on  organic  disease  of  the 
nervous  centres  are  necessarily  fatal. 

Treatment. — Until  we  obtain  a  better  insight  into  the  path- 
ology of  these  cases,  our  treatment  must  be  necessarily  empirical. 
Hitherto  the  indications  pursued  have  been  mostly  contined  to 
efforts  to  subdue  the  more  palpable  symptoms — the  thirst  and 
diuresis.  The  means  used  for  this  purpose  have  been  various. 
J.  Frank  considered  nitrate  of  potash  in  large  doses  as  a  specific; 
in  some  of  the  recorded  cases  it  proved  of  decided  service ;  in 
others  it  as  completely  failed.  Camphor  and  valerian  were  used 
in  a  number  of  the  French  cases,  and  sometimes  with  sucfcess. 
Trousseau  speaks  in  high  terms  of  valerian,  and  cites  the 
authority  of  Kayer  as  additional  evidence  of  its  eflicacy.  Trous- 
seau gave  it  in  large  doses.  In  one  case,  which  ended  in  com- 
plete and  permanent  recovery  in  four  months,  the  extract  was 
gradually  pushed  to  the  enormous  dose  of  one  ounce  daily;  his 
ordinary  dose  would  appear  to  be  two  and  a  half  drachms  a  day. 
Eayer  obtained  rapid  success  in  a  boy  who  suffered  from  poly- 


240  DIABETES    INSIPIDUS. 

uria,  with  emaciation  and  nervous  symptoms,  by  means  of  the 
powder  of  valerian.  In  the  case  of  the  boy  alluded  to  at  p.  238, 
the  valerianate  of  zinc  appeared  to  produce  a  good  effect.  It  was 
given  in  pill,  in  gradually  increasing  doses,  until  20  grains  a  day 
had  been  reached.  The  urine  fell  from  15  to  5  pints  a  day,  and 
the  thirst  and  dryness  of  the  tongue  were  greatly  diminished. 

Enforced  abstinence  from  fluids  was  tried  in  a  number  of 
cases;  and,  in  one  recorded  by  Becquerel,  with  good  effect;  but 
in  nearly  all  the  others  it  was  not  only  unsuccessful,  but  was 
followed  by  decided  aggravation  of  the  general  suffering,  and  in 
some  cases  by  symptoms  of  threatening  or  actual  ursemic  poison- 
ing. The  fate  of  l)r.  Strange's  patient  is  particularly  instructive 
on  this  point.  In  one  of  my  own  cases  opium  produced  great 
diminution  of  the  thirst  and  diuresis,  but  the  patient's  distress 
was  so  increased  that  I  was  compelled  to  suspend  the  use  of  the 
remedy. 

Dr.  MurrelP  obtained  good  results  from  the  administration  of 
belladonna  and  ergot,  in  a  case  where  the  disease  followed  a  fall 
on  the  head.  He  believed  that  here  there  was  a  lesion  of  the 
sympathetic  and  consequent  relaxation  of  the  renal  vessels, 
which  would  probably  be  overcome  by  the  drugs  administered. 
In  other  hands,  also,  ergot  has  met  with  considerable  success. 

Among  other  remedies  occasionally  followed  by  success  were 
iron,  gall-nuts,  lime  water,  cream  of  tartar,  iodide  of  mercury, 
iodide  of  potassium,  and  pilocarpin.  Dr.  Kennedy  ("Practi- 
tioner," vol.  20,  p.  94)  has  recorded  five  cases  in  which  great 
benefit  was  obtained  from  drachm  doses  of  dilute  nitro-muriatic 
acid. 

One  of  the  most  frequent  incidents  in  the  history  of  diabetes 
insipidus  is  the  temporary  suspension  of  the  thirst  and  diuresis 
on  the  occurrence  of  some  intercurrent  febrile  affection,  and  in 
two  instances  the  suspension  proved  permanent.  A  hint  for 
treatment  may  be  taken  from  this.  The  application  of  a  large 
blister  on  the  nape  of  the  neck  or  the  epigastrium  (according  as 
the  associated  symptoms  and  the  anamnesis  point  to  the  nervous 
or  the  digestive  system),  might  in  some  cases  have  the  same 
beneficial  effect  as  a  spontaneous  inflammation.  In  the  case 
treated  with  opium,  just  alluded  to,  a  blister  to  the  pit  of  the 
stomach  proved  of  more  benefit  than  any  of  the  numerous 
means  previously  employed. 

The  application  of  the  constant  galvanic  current  has  been  tried, 
with  a  promise  of  success.  Dr.  M.  Seidel  tried  this  treatment  in 
a  woman,  ?et.  29,  suffering  from  diabetes  insipidus.  He  applied 
one  pole  of  a  strong  battery  over  the  loins  near  the  spine,  and 
pressed  the  other  pole  as  deeply  as  possible  upon  the  correspond- 

1  Brit.  Med.  Journ.,  i.  1876. 


APPENDIX.  241' 

ing  liypocbondrium;  each  side  was  daily  galvanized  for  5 
minutes.  In  8  days  the  urine  had  fallen  from  5957  c.  c.  to  4600 
c.  c,  and  after  three  weeksto  2300  c.  c.,  and  next  month  to 
190 i  c.  c.  Simultaneously  the  weight  of  the  body  increased  by 
nine  pounds.  The  amendment  was  found  to  be  maintained  at 
the  end  of  three  months.^  Kiilz  obtained  very  favorable  results 
in  two  cases  treated  for  some  weeks  by  a  constant  battery  of  80 
to  40  elements.  He  applied  one  pole  as  high  as  possible  to  the 
nape  of  the  neck  and  the  other  to  the  loins  or  epigastrium. 
The  most  effective  way  appeared  to  be  to  apply  the  positive  pole 
to  the  nape  and  the  negative  pole  first  to  the  loins  for  four 
minutes,  and  then  to  the  pit  of  the  stomach  for  four  minutes. 
Dr.  Althaus^  has  recorded  a  case  in  which  immediate  improve- 
ment resulted  from  the  application  of  the  constant  current.  The 
current  was  applied  to  the  occiput,  its  direction  being  repeatedly 
reversed. 

The  secondary  symptoms — dryness  of  the  skin,  epigastric  and 
lumbar  pains,  etc.,  must  be  treated  by  warm  baths,  alkaline 
tonic  infusions,  sedative  and  anodyne  remedies. 


APPENDIX. 


Cases  characterized  by  excessive  diuresis  and  thirst ;  urine  of  very 
low  specific  gravity,  but  containing,  or  having  contained,  a  trace 
of  sugar. 

Cases  of  this  type  form  an  intermediate  group  between  in- 
sipid and  saccharine  diabetes ;  and  their  existence  completes,  in 
an  exquisite  manner,  the  ^correspondence  between  the  results 
obtained  by  Bernard  from  artificial  injuries  to  different  parts  of 
the  floor  of  the  fourth  ventricle,  and  clinical  observations. 

Two  cases  of  this  class,  following  fracture  of  the  skull,  are 
reported  by  Fischer  ("Archives  Gen.,"  Oct.  1852).  In  one,  the 
sugar  amounted  to  0.32  per  cent.  In  the  other,  in  which  there 
was  a  voracious  appetite  as  well  as  intense  thirst,  there  was  0.5 
per  cent,  on  the  first  day  after  the  accident,  and  0.6  per  cent,  on 
the  third  day.  The  fioor  of  the  fourth  ventricle  was  examiaied 
in  both  instances  after  death,  and  was  alleged  to  be  healthy;  in 
the  second  case  (which  terminated  in  tetanus),  the  whole  brain 
and  cerebellum,  so  far  as  could  be  made  out,  were  uninjured. 

A  third  case,  arising  spontaneously,  is  related  by  Trousseau. 
The  disease  had  already  existed  four  years  without  serious 
giving  way  of  the  health.     The  examination  of  the  urine  (by 

1  Schmidt's  Jahrb.,  Bd.  130,  S.  97.  '^  Med.  Times,  1880,  ii.  p.  617. 

16 


242  DIABETES    INSIPIDUS. 

Boucharclat)  on  two  occasions,  at  considerable  intervals  of  time, 
showed  a  trace  of  sugar.  The  quantity  of  urine  varied  from  12 
to  37  litres  a  day.  Among  the  secondary  symptoms  were  im- 
potence, lumbar  pains,  and  a  remarkable  tolerance  of  alcoholic 
drinks.  This  man  derived  considerable  benefit,  but  was  not 
cured,  under  the  use  of  valerian. 

A  fourth  case  is  recorded  in  the  "  Gaz.  des  Hopitaux"  for 
1861.  A  man,  set.  35,  was  afflicted  for  many  years  with  poly- 
uria, passing  daily  from  10  to  12  pints. of  urine,  specific  gravity 
1001-1007.  He  was  the  subject  of  chronic  phthisis  when  in  the 
Hotel  Dieu,  under  Trousseau,  in  1861.  There  was  then  not  a 
particle  of  sugar  or  albumen  in  the  urine;  but  when  he  was  an 
inmate  of  the  Hop.  St.  Antoine,  in  1856,  a  trace  of  sugar  was 
found.  Acute  pulmonary  symptoms  came  on  at  last,  with  pur- 
pura. The  urine  rapidly  diminished  in  quantity,  and  the  patient 
sank.  The  autopsy  was  performed  by  Luys.  The  floor  of  the 
fourth  ventricle  was  more  vascular  than  natural;  large  vascular 
trunks  mapped  the  surface;  yellow  spots  were  seen  scattered 
over  the  upper  part,  near  the  crura  cerebri.  Similar  patches 
were  found  below  the  points  of  origin  of  the  radicles  of  the 
portio  mollis.  On  section,  the  whole  gray  substance  was  found 
unusually  vascular,  and  of  a  rosy  hue.  Microscopic  examina- 
tion showed  that  these  alterations  in  color  were  due  to  fatty 
degeneration  of  all  the  nerve  cells  of  the  corresponding  regions. 

A  fifth  case  is  reported  by  Dr.  lialfe  ("Lancet,"  1881,  i. 
p.  407).  A  gentleman,  set.  37,  had  suffered  from  mild  glyco- 
suria for  eighteen  months.  The  glycosuria  occasionally  disap- 
peared, but  a  certain  amount  of  polyuria  (2500  c.  c.  daily)  with 
excessive  excretion  of  phosphates  was  constant.  The  patient 
improved  under  codeia  and  opium,  with  tepid  saline  douches. 

A  case  which  may  be  classed  with  these  occurred  to  mj'self 
some  years  ago.  A  man  of  sixty-five  was  brought  into  the 
Manchester  Infirmary  in  an  apoplectic  fit.  He  died  after  lying 
for  six  hours  in  deep  coma.  During  this  period  he  flooded  the 
bed  with  urine.  After  death  a  large  quantity  of  urine  was 
withdrawn  from  the  bladder.  It  had  a  specific  gravity  of  1010, 
and  contained  a  considerable  quantity  of  sugar.  A  voluminous 
clot  was  found  in  the  brain. 


CIIAPTEll    II. 

DIABETES  MELLITUS. 

The  multiplied  researches  of  recent  years  on  the  occurrence 
of  sugar  or  glucose  in  the  urine,  necessitate  the  adoption  of 
some  classification  of  cases  of  saccharine  urine. 

Cases  of  saccharine  urine  may  be  primarily  divided  into  two 
broad  classes  or  divisions. 

One  class  consists  of  instances  in  which  a  small  quantity  of 
sugar  appears  in  the  urine  for  very  short  periods,  without 
relevant  symptoms — the  circumstance  being  a  temporary  and 
incidental  consequence  of  some  physiological  or  pathological 
antecedent  which  has  little  or  no  affinity  to  diabetes,  as  clinic- 
ally understood.  Belonging  to  this  class  are  examples  of  sac- 
charine urine  after  the  administration  of  chloroform,  after  eating 
an  excessive  quantity  of  saccharine  and  amylaceous  food,  in 
recovery  from  cholera,  and  after  a  paroxj^sm  of  whooping- 
cough,  asthma,  or  epilepsy.  These  may  be  designated  as  cases 
of  incidental  glycosuria. 

In  the  other  class  of  cases  the  glycosuria  is  more  intense:  it 
constitutes  a  permanent  symptom,  and  persists  for  considerable 
periods  of  time,  and  is  associated  with  a  serious  departure  from 
health.     To  this  class  alone  is  the  term  diabetes  at  all  applicable. 

This  second  class  again  is  divisible  into  two  groups.  In  the 
first,  the  glycosuria  is  persistent  and  intense,  and  the  flow  of 
urine  is  greatly  increased ;  this  state  of  urine  is  associated  with 
thirst,  debility,  emaciation,  and  a  train  of  grave,  fatally  tending 
symptoms,  which  constitute  a  familiar,  easily  recognized  clinical 
unit3\  This  is  the  classical  diabetes  of  authors,  and  to  this  the 
name  diabetes  was  limited,  before  our  more  refined  and  ready 
analysis  disclosed  the  presence  of  sugar  in  the  urine  in  a  number 
of  other  and  diflferent  states. 

The  second  group  embraces  those  less  serious  types  in  which 
sugar  is  present  in  the  urine,  sometimes  abundantly,  some- 
times scantily,  sometimes  persistently,  sometimes  intermittently; 
always  with  a  weakl}^  condition  of  health,  but  without  thirst  or 
conspicuous  emaciation,  often,  indeed,  with  corpulence;  without 
any,  or  only  slight,  increase  in  the  quantity  of  urine,  and  with- 
out that  fixed  tendency  to  death  whicli  stamps  the  first  group — 
occurring  also  generally  in  advanced  years,  or  at  least  beyond 
the  time  of  early  manhood.     Some  of  these  milder  t^'pes  of  gly- 


244 


DIABETES    MELLITUS. 


cosuria  will  be  separately  noticed  at  the  end  of  the  present 
chapter. 

ETIOLOGY  OF  DIABETES  MELLITUS. 

In  the  decade  1851-60,  4546  deaths  from  diabetes  were  regis- 
tered in  England  and  Wales,  being  an  annual  average  ot  454.^ 
Of  the  total  number  3032  were  males,  and  1514  females,  show- 
ing that  in  this  country  diabetes  is  twice  more  common  in  men 
than  women.  Up  to  the  age  of  puberty,  the  two  sexes  appear 
to  be  equally  liable  to  diabetes ;  but  from  that  period  on  to  old 
age  the  liability  of  the  male  sex  maintains  an  increasing  ratio, 
as  may  be  seen  from  the  following  table : 


Table  showing  the  number  of  deaths  from,  diabetes,  at  different  periods  of 
life  in  the  two  sexes.^ 


PEEIOB  OF  LIFE. 

Under 

5 

yrs. 

5-10 

yrs. 

10-15 

yrs. 

15-25 

yrs. 

25-35 
yrs. 

35-45 
yrs. 

45-55 
yrs, 

55-65 
yrs. 

65-75 
yrs. 

75  years 

and 
upwards. 

All 

ages. 

Deaths  in  males. 
Deaths  in  females 

28 

23 

40 
42 

97 
78 

378 
220 

468 

282 

502 
261 

550 
247 

500 
191 

364 
144 

105 
26 

3032 
1514 

Total  males  and  fe-\ 
males.                      / 

51 

82 

1 
175    598 

750 

763 

797 

691 

508 

131 

4546 

Dr.  Dickinson  has  shown  that  diabetes  is  more  common  in 
agricultural  than  in  urban  districts,  and  is  also  more  frequent 
in  the  colder  parts  of  the  country. 

Diabetes  prevails  chiefly  among  3^oung  and  middle-aged 
adults.  It  is  rare  under  live  years  of  age.  The  youngest  ex- 
ample that  has  come  under  my  notice  was  a  boy  of  three  years; 
but  in  the  Registrar-General's  "Reports"  for  1851-60,  ten  deaths 
from  diabetes  under  the  age  of  one  year  are  registered,  and  as 
many  as  thirty-two  under  the  age  of  three  years.  The  mortality 
from  diabetes  attains  its  maximum  between  the  ages  of  twenty- 
five  and  sixty-five  years,  and  maintains  itself  between  these 
epochs  with  tolerable  uniformity.  In  extreme  old  age  deaths 
from  diabetes  are  more  rare,  not  only  absolutely,  but  as  com- 
pared to  the  mortality  from  all  causes. 

The  development  and  exercise  of  the  sexual  functions  appear 
to  have  a  marked  eft'ect  in  increasing  the  liability  to  diabetes 
in  both  sexes;  and  the  diminished  frequency  of  the  disease  in 
women  after  the  age  of  lorty-five  (as  compared  with  men)  cor- 
responds with  the  earlier  decline  of  the  sexual  activity  in  the 

1  In  the  eight  years  1861-8  the  annual  average  of  deaths  from  diabetes  was  628. 

2  Construc1;ed  from  the  Eegi'-trar-General's  Reports,  for  1851-60,  for  England  and 
Wales.     Mean  population  for  the  decade,  19,000,000. 


ETIOLOGY.  245 

female  sex.  The  maximuni  mortality  iu  males  is  between  forty- 
live  and  iifty-five  years;  in  females  between  twenty-iivo  and 
thirty -five  years. 

Dr.  Matliews  Duncan  has  pointed  out  tliat  wliile  a  sliirht  ,ii;]y- 
cosuria  is  common  in  pre<i:;nant  women,  sornetirnos  true  diabetes 
supervenes,  and  is  tiien  very  danii:;erous  to  the  life  of  Ijoth  mother 
and  child  ("  Lancet,"  1882,  ii.  pr944). 

Hereditary  Influence  is  a  distinct  predisposijif?  cause  of 
diabetes;  and  I  have  known  a  considerable  number  of  instances 
in  which  the  disease  has  run  in  families.  Seegen  mentions  a 
brotlier  and  sister  who  were  both  diabetic.  A  short  time  ago  I 
had  under  my  care  an  uncle  and  niece  similarly  affected.  I 
have  also  a  note  of  a  family  of  eig-ht  children,  all  of  whom 
became  diabetic,  though  the  parents  were  healthy.  Sir  II. 
Marsh^  refers  to  a  family  in  which  diabetes  could  be  traced  to 
the  second  generation,  and  to  another  family  in  which  it  could 
be  traced  through  four  generations.  Schmidtz,  of  JSTeuenahar, 
traced  heredity  ui  248  out  of  600  cases  {see  "Lancet,"  i.,  1883). 
Diabetic  patients  have  frequently  been  observed  to  belong  to 
families  in  wdiich  phthisis  and  epilepsy  prevailed.  One  of  my 
patients  was  one  of  four  survivors  out  of  a  family  of  twenty- 
five;  twenty  of  these  had  died,  after  reaching  adult  age,  of 
lingering  complaints  with  great  emaciation,  probably  phthisis 
or  diabetes. 

The  subjects  of  obesity  and  of  the  gouty  diathesis  are  very 
prone  to  a  mild  form  of  diabetes.^ 

ExciTiNa  Causes. — The  exciting  cause  of  diabetes  is  often 
obscure.  In  a  considerable  number  of  cases  the  disease  has 
broken  out  soon  after  exposure  to  luet  and  cold;  in  others  after 
copious  drinking  of  cold  fluids  while  the  body  was  in  a  heated 
state.  Cases  arising  from  cold,  generally  present  a  train  of 
neuralgic  or  quasi  rheumatic  symptoms,  l)efore  the  breaking  out 
of  the  thirst  and  diuresis.  Excessive  use  of  saccharine  and  amy- 
laceous articles  of  food,  antecedent  acute  febrile  diseases,  abuse  of 
alcoholic  drinks,  have  all  been  noted  as  probable  exciting  causes 
of  diabetes. 

The  disease  is  sometimes  traced  to  a  violent  mental  emotion. 
In  one  of  my  patients  it  followed  on  distress  of  mind  caused  by 
an  unjust  suspicion  of  theft;  in  another  it  followed  the  burn- 
ing down  of  his  place  of  business;  in  a  third  it  was  attributed 
to  anxiety  attendant  on  a  Chancery  suit.  Raver  mentions  a  case 
of  diabetes  coming  on  after  a  violent  fit  of  anger,  and  Laudouzy 

1  Dublin  Quarterly,  1854,  p.  17,  note. 

2  From  a  discussion  in  the  Ac;idemy  of  Medicine  of  Paris,  it  would  appear  that 
glycosuria  is  very  common  among  those  who  have  suffered  fmrn  malaria.  See 
Hayem's  Revue,  1883,  li.  p.  164  Sir  J.  Fayrer's  experience  also  confirms  this 
opiiiion.     (Brit.  Med.  Journ.,  1882,  i.  p.  529.) 


246  DIABETES    MELLITUS. 

another  after  violent  grief.    Dr.  Dickinson  cites  several  striking 
exam|3les  of  diabetes  following  excessive  mental  anxiety. 

Organic  diseases  of  the  brain  and  cord  have,  of  late  years,  been 
shown  to  be  occasionally  the  exciting  cause  of  diabetes.  These 
cases  are  of  special  interest  as  bearing  on  the  discoveries  of 
Bernard  and  others,  on  the  artificial  production  of  glycosuria 
in  animals  by  cutting  or  puncturing  various  parts  of  the  nervous 
system. 

On  Feb.  19,  1871,  I  saw,  with  Dr.  Eansome,  of  Bowdon,  a 
contractor,  aged  55.  He  had  been  formerly  in  the  habit  of 
taking  spirits  freely — but  three  years  ago  he  had  a  succession  of 
epileptic  fits,  in  consequence  of  which  he  was  induced  to  take 
light  claret  only.  The  fits  then  ceased.  For  the  last  twelve 
months  he  had  taken  largely  of  milk — sometimes  four  or  five 
quarts  daily.  He  came  under  Dr.  Ransorae's  treatment  in  Jan. 
1871,  for  loss  of  memory  and  mental  confusion.  He  was  a  stout, 
florid  man — though  somewhat  thinner  than  he  had  been.  There 
was  much  thirst  and  a  ravenous  appetite.  The  pulse  varied 
from  120  to  140.  The  urine  amounted  to  between  10  and  12 
pints  daily,  and  was  highly  saccharine.  By  strict  dieting  it  was 
reduced  to  7  pints,  wdth  a  sp.  gr.  of  1032-40.  On  June  1st  he 
had  a  slight  paralj'tic  seizure  affecting  the  right  hand  and  arm — 
with  loss  of  speech  for  a  few  minutes.  His  loss  of  memory  was 
complete  for  recent  events — even  a  few  minutes  after  their  oc- 
currence— but  he  retained  full  recollection  of  matters  which  had 
occurred  before  his  illness.  This  man  died  some  months  later. 
A  naked-ej^e  examination  of  the  brain  did  not  reveal  any  pal- 
pable signs  of  disease. 

Pavy  cites  the  following  examples  :  A  late  alderman  of  the 
city  of  London  was  seized  with  cerebral  hemiplegia.  His  urine 
was  tested  by  Dr.  Barlow  at  the  period  of  the  attack  and  found 
to  be  free  from  sugar.  There  had  also  been  nothing  from  the 
symptoms  and  history  to  lead  to  the  suspicion  that  sugar  would 
be  found.  Shortly  afterwards,  however,  strongly  marked  dia- 
betes set  in.  A  member  of  the  medical  profession,  who  was 
seen  by  Sir  W.  Gull,  was  seized  at  the  age  of  fifty-two  with  an 
apoplectic  fit,  from  which  he  recovered,  with  hemiplegia,  how- 
ever, of  the  left  side  of  the  body  remaining  behind.  Five  weeks 
after  the  fit,  this  person  who  had  never  previously  presented  any 
symptoms  of  diabetes,  began  rapidly  to  emaciate,  which  led  to 
an  examination  of  the  urine  being  made.  A  highly  saccharine 
state  of  it  was  found  to  exist. 

Dr.  Kichardson^  relates  a  case  of  diabetes  in  which  convul- 
sions and  symptoms  of  meningitis  occurred  during  life :  after 
death  an  ossific  growth  was  found  pressing  on  the  pons  Varolii, 

'  Med.  Times  and  Gaz.,  March  and  May,  1862. 


ETIOLOGY.  247 

and  an  abscess  in  the  posterior  cerebral  lobes.  Dompeling  re- 
lates a  case  of  diabetes  in  whicb  a  tumor  as  lar<(e  as  a  nut  was 
found  after  death,  occupyinii,'  the  whole  of  the  right  half  of  the 
medulla  oblongata  ("Arch.  Gen./'  May,  1809). 

E,  Fritz  has  collected  an  interesting  series  of  cases  of  dia- 
betes associated  with  various  organic  diseases  of  the  brain  and 
cord  (cerebral  softening,  tumors  of  the  Y)ia  mater,  genei-al 
paralysis,  and  myelitis). 

Mr.  Morison  has  rei)orted  a  case  of  glycosuria  accompanied 
by  organic  disease  of  the  brain.*  The  patient  was  a  man  aged 
49  years,  who  had  a  history  of  syphilis,  and  had  also  suffered 
from  nephritic  colic.  Five  3'ears  before  death  he  had  com- 
plained of  aphasia,  and  paresis  of  the  right  side,  from  whiclj  he 
recovered  in  a  few  days,  but  since  that  time  had  urinated  exces- 
sively. About  two  3'ears  and  a  half  before  death  he  was  found 
to  be  suffering  from  hemian?esthesia  of  the  left  side,  and  progres- 
sive paresis  of  the  same  side.  The  patient  in  addition  showed 
the  symptoms  of  glycosuria  rather  than  of  true  diabetes.  Post- 
mortem, there  were  found  cysts  in  the  right  optic  thalamus,  and  a 
granular  condition  of  the  lower  three-fourths  of  the  fourth  ven- 
tricle. 

De  Jonge  reports  a  case  in  the  "  Archiv  f.  Psychiatric, "  xiii, 
p.  668,  in  which  a  tuberculous  tumor  was  found  in  the  medulla 
of  a  patient,  who  during  life  had  suffered  from  diabetes. 

Still  more  numerous  are  the  cases  in  which  diabetes  has  fol- 
lowed external  wjuries  to  the  brain  and  other  parts.  Dr.  Goolden^ 
has  published  a  series  of  such  examples ;  and  P.  Fischer  has 
increased  the  list  to  twenty-one  cases,  and  ably  analyzed  them. 
The  injuries  consisted  of  blows  and  falls  on  the  forehead,  vertex, 
and  occiput — sometimes  with  and  sometimes  without  fracture  of 
the  skull.  In  some  instances  there  was  temporary  loss  of  con- 
sciousness, in  others  not. 

In  addition  to  cases  of  violence  directly  affecting  the  brain,  a 
large  number  (twenty-two  cases)  are  cited  by  Fischer  of  blows 
on  the  face,  fractures  of  the  vertebrse,  blows  on  the  loins,  the 
thorax,  the  abdomen,  contusions  of  the  kidney  and  liver,  violent 
efforts,  etc.,  which  have  been  followed  by  diabetic  symptoms. 

Some  of  these  traumatic  cases  were  examples  of  confirmed 
diabetes  of  the  ordinary  type,  and  ran  a  fatal  course.  Others 
were  of  much  milder  type,  transitory  in  their  duration,  passing* 
away  on  the  subsidence  of  the  cerebral  symptoms.  In  some  of 
them  the  diabetic  symptoms  commenced  at  the  time  of  the 
accident,  or  shortly  after;  in  others,  not  until  some  months  had 
elapsed  after  the  injury. 

In  a  certain  proportion  of  the  traumatic  cases  (eight  out  of 

1  Ed.  Med.  Journ.,  March,  1878. 

^  Lancet,  June  and  July,  1854,  and  Med.  Times,  Dec.  1854. 


248  DIABETES    MELLITUS. 

forty-three  collected  by  Fischer)  the  urinary  disorder  consisted 
of  simple  polyuria. 

It  is  probable  that  in  all  the  traumatic  cases  the  injury  (how- 
ever different  its  seat)  implicated  some  part  of  the  sympathetic 
nervous  system,  either  within  the  cranium  or  spinal  cord,  or  in 
its  peripheral  distribution. 

Lesions  of  the  peripheral  nervous  system  may  give  rise  to 
glycosuria,  and  occasionally  it  is  said  to  diabetes,  probably  by 
reflex  action.  Neuralgias  of  the  fifth  pair  of  nerves,  and  of  the 
sciatic  nerves,  seem  specially  prone  to  produce  this  condition. 

In  his  recent  treatise  on  diabetes,  Frerichs  lays  great  stress 
on  the  influence  of  lesions  of  the  nervous  system  in  producing 
the  disease.  Out  of  165  cases,  he  was  able  to  trace  some  form 
of  nervous  lesion  in  75.  The  nervous  disturbances  comprised 
organic  lesions  of  the  brain,  mental  disorders,  affections  of  the 
peripheral  nerves,  concussion  of  the  brain,  and  excessive  mental 
strain,  trouble,  and  worry. 

SYMPTOMS. 

The  invasion  of  diabetes  is  generally  insidious.  The  disease 
is  seldom  recognized  until  it  has  existed  some  weeks  or  months. 
The  initial  symptoms  (malaise  and  slight  emaciation)  pass  un- 
noticed, because  the  appetite  continues  good;  but  the  patient's 
suspicions  are  at  length  aroused  by  the  increasing  frequency  of 
the  calls  to  make  water,  and  an  incommodious  thirst.  The  dis- 
ease sometimes,  however,  attains  a  high  intensity  in  a  few  weeks. 
In  one  of  my  cases  as  much  as  fifteen  pints  of  urine  a  day  were 
secreted  in  the  third  week. 

As  the  disease  advances,  it  assumes  its  characteristic  features. 
The  thirst  becomes  insatiable,  the  appetite  excessive  or  vora- 
cious, the  skin  harsh,  dry,  and  scurfy;  the  patient  emaciates; 
the  countenance  wears  an  appearance  of  suffering,  and  the  fea- 
tures are  drawn ;  a  distressing  sinking  is  felt  at  the  pit  of  the 
stomach;  the  tongue  is  glazed  and  furrowed;  a  scanty,  tena- 
cious mucus  gathers  in  the  mouth,  which  is  parched  and  clamni}^; 
the  urine  rises  to  eight,  twelve,  or  more  pints  in  the  twenty-four 
hours;  this  urine  is  of  a  pale  straw  color;  its  density  varies 
from  1035  to  1045  or  higher;  and  it  contains  a  large  proportion 
of  sugar ;  the  virile  powers  fail ;  and  the  mental  faculties  lose 
their  wonted  vigor. 

If  the  malady  proceeds  unchecked,  these  symptoms  increase 
in  intensity.  The  emaciation  and  loss  of  strength  attain  an 
extreme  degree ;  pulmonary  symptoms  resembling  those  of 
phthisis  often  make  their  appearance,  and  advance  with  alarm- 
ing rapidity;  or  colliquative  diarrhoea  sets  in;  hectic  fever  is 
established;  the  urine  now  diminishes  in  quantity,  perhaps  loses 


SYMP'l'OMS.  *249 

its  sugar  and  becomes  albuminous;  the  legs  become  ojclematous 
and  the  unfortunate  sufierer  is  at  length  released,  often  very 
suddenly,  either  by  sheer  exhaustion,  or  he  is  carried  off  by 
one  of  the  numerous  complications  of  the  disease. 

Some  of  these  symptoms  require  a  more  detailed  consid- 
eration. 

The  Urine. — The  essential  features  of  the  urine  in  diabetes 
are  its  excessive  quantity  and  the  presence  of  sugar.  Tlie  ]»ro- 
portion  of  the  latter  varies  from  8  to  12  per  cent.  It  is  chemi- 
cally identical  with  grape-sugar  or  glucose.  The  quantity  of 
sugar  excreted  daily  ranges  from  15  to  25  ounces;  but  it  may 
amount  to  two  pounds  or  more,  or  fall  to  an  ounce  or  less.  Tbe 
proportion  of  sugar  is  always  increased  after  food,  and  dimin- 
ished after  fasting.  After  the  use  of  starchy  or  saccliarine 
substances,  the  increase  is  much  greater  than  after  animal  food. 
In  many  of  the  milder  cases,  and  probably  in  the  earliest  stages 
of  all,  the  urine  becomes  free  from  sugar  when  starch  and  sugar 
are  entirely  withdrawn  from  the  diet;  but  in  confirmed  cases 
the  urine  still  continues  saccharine — though  in  greatly  dimin- 
ished intensity — when  the  diet  is  purely  animal,  and  even  when 
no  food  at  all  is  taken.  In  this  last  case  the  sources  of  the 
sugar  are  necessarily  the  tissues  of  the  body. 

The  density  of  diabetic  urine  usually  fluctuates  a  few  de- 
grees above  or  below  1040 ;  it  may  rise  to  1055  or  1060,  or  sink 
to  1015. 

Intercurrent  inflammatory  or  febrile  attacks  cause  the  sugar 
to  diminish,  or  even  temporarily  to  disappear.  Toward  the 
approach  of  death  a  similar  diminution  is  observed. 

The  quantity  of  the  urine  oscillates  usually  between  8  and  15 
pints  daily;  but  it  has  been  known  to  exceed  32  pints.  When 
the  diet  is  restricted  to  animal  food,  the  urine  is  generally  re- 
duced to  four  or  five  pints  a  day.  The  quantity  of  the  urine  is 
about  equal  to  the  liquids  imbibed.  The  opinions  formerly 
held,  that  the  urine  exceeded  the  ingested  liquids,  and  that  the 
body  absorbed  water  through  the  lungs  and  skin,  or  generated 
it  de  novo  from  the  elements  of  the  food  and  tissues,  are  quite 
unsupported  by  more  rigid  observations  of  recent  date. 

When  the  flow  is  considerable  the  urine  has  a  ^ery  pale  straw 
tint  and  a  peculiarly  bright  aspect.  It  speedily  becomes  opales- 
cent when  exposed  to  warm  air,  and  in  a  few  hours  fermer;ts 
with  abundant  disengagement  of  gas  and  production  of  sporules 
and  filaments  of  the  yeast  plant.  These  latter  form  a  white 
flour-like  deposit  in  diabetic  urine  after  it  has  been  kept  awhile. 

When  the  flow  does  not  exceed  four  or  five  pints,  the  color 
and  General  appearance  of  the  urine  are  natural. 

With  regard  to  the  ordinary  constituents  of  the  urine,  no  par^ 
ticular  alteration  takes  place  in  their  rate  of  excretion  be^'oud 


260  DIABETES    MELLITUS. 

a  diminution  of  their  proportion  to  the  water,  and  (generally) 
some  absolute  increase  of  their  quantity.  Very  contradictory 
statements  have  appeared  on  this  point;  but  the  more  trust- 
worthy observations  appear  to  support  the  above  conclusion, 
especially  with  respect  to  urea.  Uric  acid  is  often  difficult  to 
detect,  owing  to  the  immense  proportion  of  water;  but  it  is  not 
really  absent,  as  has  been  alleged;  and  when  the  volume  of  the 
urine  is  reduced  to  four  or  live  pints  a  day,  uric  acid  frequently 
forms  an  abundant  deposit  of  large  dark  red  crystals.  More 
rarely  I  have  observed  oxalate  of  lime;  and  in  one  instance  a 
persistent  deposit  of  crystallized  phosphate  of  lime. 

The  presence  of  a  small  quantity  of  albumen,  and  even  of 
blood,  is  not  uncommon  in  advanced  cases,  and  constitutes  an 
untoward  sign.  In  a  gouty  old  gentleman  who  was  passing 
four  pints  of  a  moderately  saccharine  urine  a  day,  I  detected 
(in  addition  to  a  little  albumen)  transparent  fibrinous  casts  of 
the  uriniferous  tubes. 

Thirst  is  one  of  the  earliest  and  most  persistent  symptoms  of 
diabetes,  and  has  often  led  to  its  detection.  Diabetic  patients 
will  generally  drink  from  8  to  12  pints  a  day;  but  sometimes 
they  imbibe  as  much  as  25  or  35  pints  a  day.  ^Nevertheless, 
this  enormous  potation  does  not  sufiice  to  quench  the  intolerable 
thirst,  na}',  it  seems  even  to  intensify  it.  A  perpetual  painful 
dryness  of  the  mouth  and  fauces  remains  in  spite  of  a  deluge  of 
water.  Patients  have  even  been  known  to  drink  their  own 
urine  to  allay  their  craving  for  fluids. 

The  immediate  cause  of  this  thirst  is,  probably,  the  existence 
of  sugar  in  the  blood.  This  crystalline  substance,  like  any  other 
crystalloid,  creates  a  demand  for  water  to  eftect  its  dissolution 
and  elimination  from  the  body.  On  the  other  hand,  the  con- 
sumption of  large  quantities  of  water  seems  to  aggravate  the 
disease,  by  accelerating  the  disintegration  of  the  tissues. 

Inordinate  appetite  is  not  nearly  so  constant  a  symptom  as 
excessive  thirst;  and  in  the  course  of  the  complaint  there  is  not 
unfrequently  complete  anorexia.  Toward  the  fatal  termination 
a  loathing  for  food  of  every  sort  often  prevails,  and  is  accom- 
panied by  rapid  sinking  of  the  powers  of  life. 

Emaciation  is  generally  a  prominent  symptom;  and  the  degree 
of  it  is  proportional  to  the  intensity  and  duration  of  the  disease. 
The  disappearance  of  fat  is  probably  not  without  direct  con- 
nection with  the  unnatural  transformation  of  the  amyloid  sub- 
stance of  the  liver  into  sugar;  as  it  seems  highly  probable  that 
the  normal  destination  of  this  is,  partly  at  least,  to  nourish  the 
adipose  tissues  of  the  body.  Emaciation  is,  however,  not  an 
invariable  concomitant  of  diabetes.  One  of  my  patients  weighed 
over  15  stone,  though  he  had  been  voiding  daily  12  pints  of 


SYMPTOMS.  251 

highly  saccharine  urine  for  some  moiitliH,  One  of  Prout'H  dia- 
bedc  patients  weighed  23  stone!  This  obese  class  of  cases  is 
markedly  less  severe,  and  of  more  hopeful  prognosis  than  the 
generality. 

The  emaciation  is  not  confined  to  the  fatty  tissues;  the  mus- 
cles become  atrojihied,  and  even  the  heart  itself.  The  enormous 
flow  of  fluid  through  the  kidneys  explains  to  some  extent  the 
excessive  emaciation  of  diabetic  patients;  for  it  has  been  shown 
by  Genth,  Bocker,  and  Mosler,  that  simple  transudation  of 
water  through  the  body  increases  the  disintegration  of  the  tis- 
sues, and  induces  rapicl  loss  of  weight,  unless  the  deficiency  be 
made  up  by  increased  supplies  of  food.  In  diabetes,  notwith- 
standing the  enormous  amount  of  aliments  ingested, the  defective 
state  ofthe  digestive  organs  prevents  the  possibility  of  suitable 
compensation  by  increasing  the  supply  from  without.  In  agree- 
ment with  this  view,  it  is  found  that  when  the  flow  of  urine  in 
diabetic  patients  is  brought  down  by  appropriate  treatment  to 
three  or  four  pints  a  day  there  is  usually  no  further  loss  of 
weight,  or  even  the  patient  recovers  some  of  what  he  has  lost, 
though  the  urine  still  continue  saccharine. 

Dryness  of  the  ski7i  is  a  usual  and  very  unpleasant  symptom 
of  diabetes,  and  its  intensity  is  proportional  to  the  diuresis. 
Some  diabetic  patients,  however,  sweat  freely  throughout  their 
complaint;  others  only  begin  to  sweat  on  the  advent  of  hectic 
fever. 

The  temperature  of  the  body  is  usually  normal — often  sink- 
ing a  little  below  the  normal — sometimes  even  markedly  so. 
Even  in  intercurrent  inflammations  it  scarcely  rises  above  the 
healthy  standard. 

The  prevalence  of  boils  is  a  curious  occasional  coincidence  of 
saccharine  urine.  In  a  gentleman  recently  under  my  care,  suc- 
cessive crops  of  boils  were  the  earliest  symptom  of  the  disease. 
Sometimes  they  constitute  veritable  furunculi,  and  as  many  as 
twenty-two  have  been  counted  at  the  same  time  on  a  diabetic 
patient.  They  may  even  be  the  immediate  cause  of  death. 
Other  cutaneous  affections  are  sometimes  seen,  less  frequently 
than  boils,  namely,  general  eczema,  psoriasis,  and  impetigo. 

An  erythematous  and  excoriated  condition  of  the  urethral 
oritice  (due  to  the  irritation  of  the  saccharine  urine)  is  occasion- 
ally a  source  of  great  discomfort;  and  in  the  female,  heat  and 
itching  about  the  vulva  are  common  and  distressing  symptoms. 

Dr.  Garron  states  that  oedema  of  the  legs  is  a  constant  feature  in 
diabetes.  It  certainly  is  very  common ;  and  the  flat  surfaces  of 
the  tibi?e  can  nearly  always  be  made  to  pit  on  firm  pressure, 
even  when  no  fulness  exists  about  the  ankles.  I  am  satisfied, 
however,  that   this   pitting,  when  very   slight,  is   not   due  to 


252  DIABETES    MELLITUS. 

oedema,  but  rather  to  the  soft  atonic  state  of  the  subcutaneous 
tissues. 

Ascites  and  oedema  of  the  arms  and  hands  occurred  in  one  of  my 
cases.  Ascites  is  also  mentioned  in  one  case  by  Fischer,  where 
the  disease  was  complicated  with  cataract. 

The  dryness  of  the  mmith  usually  corresponds  to  that  of  the 
general  surface.  The  tongue  is  commonly  red,  preternaturally 
clean,  cracked,  and  denuded  of  epithelium.  In  the  less  severe 
cases,  or  when  amelioration  has  been  brought  about  by  treat- 
ment, the  tongue  is  moist,  and  coated  with  a  thin  yellowish- 
white  fur.  In  the  majority  of  diabetic  patients  the  teeth  are 
gradually  destroyed  by  caries;  and  the  gums  become  spongy, 
swollen,  loosened  from  the  teeth,  and  liable  to  bleed.  The 
destruction  of  the  teeth  is  attributed  by  Falck  to  the  excessive 
acidity  of  the  saliva,  due  to  the  generation  of  lactic  acid  from 
the  sugar  present  in  the  secretions  of  the  mouth. ^  Sometimes, 
however,  the  teeth  are  preserved  perfectly  in  persons  who  have 
been  diabetic  for  many  3'ears. 

The  digestive  organs  rarely  bear  the  unnatural  strain  put 
upon  them  by  the  excessive  feeding  of  diabetic  patients,  without 
at  length  resenting  the  ill-usage.  Epigastric  pains  and  a  sense 
of  sinking  at  the  scrobiculus  cordis,  flatulence,  and  occasional 
vomiting,  are  the  most  common  symptoms.  As  a  rule,  the 
bowels  are  constipated,  and  require  artificial  aid  to  promote 
their  action.  The  feces  are  generally  pale.  In  advanced  cases 
diarrhoea  not  unfrequently  occurs,  sometimes  of  a  dysenteric 
character.  This  is  a  formidable  and  generally  speedily  fatal 
complication. 

The  mental  state  suffers  a  marked  alteration  in  confirmed 
eases;  but  the  degree  and  type  of  it  vary  a  good  deal.  The 
change  most  commonly  observed,  is  a  heaviness  and  apathy,  a 
disinclination  to  mental  and  bodily  exertion,  sometimes  a  posi- 
tive drowsiness.  The  natural  firmness  of  the  character  gives 
place  to  a  deplorable  pusillanimity  and  a  want  of  moral  sense, 
which  are  foreign  to  the  individual  in  a  state  of  health.  Persons 
who  previously  have  been  above  every  equivocation  or  conceal- 
ment, resort  to  petty  cunning  and  positive  untruthfulness  to 
deceive  their  medical  attendant  as  to  their  food  and  drink. 
Nevertheless,  in  most  cases  the  intelligence  itself  is  not  troubled, 
and  continues  clear  to  the  end. 

The  sexual  functions  undergo  a  notable  declension  of  vigor 
in  advanced  cases;  and  there  is  frequently  actual  impotence 
from  failure  of  the  power  of  erection.  This  defect,  however,  is 
not  a  permanent  one ;  and  if  amelioration  take  place  the  virile 

'  Magitot  has  recently  pointed  out  that  an  alveolar  periostitis  is  very  common  in 
diabetes,  and  leads  to  the  Inss  of  the  teeth,  and  in  severe  cases  to  gangrene  of  the 
gum.     (Bull,  de  I'Acad.  deMed.,  2d  series,  vol.  x.  No.  52.) 


COURSE,   DURATION,  TERMINATION.  253 

powers  return  early.  Exceptions  to  this  rule  uIbo  occur.  ])r. 
Prout  mentions  an  instance  of  a  contirnied  dialjctic,  wIk;  married 
and  had  two  cliiUlren,  though  the  saccharine  condition  of  the 
urine  still  persisted. 

COURSE,   DURATION,  TERMINATION. 

Diabetes  is  an  essentially  chronic  disease;  its  course  is  meas- 
ured by  months  and  years.  The  ordinary  duration  of  diabetes 
is  from  one  to  three  years.  Sometimes  the  disease  runs  a  rapid 
course  and  terminates  in  a  few  months  or  weeks.  The  most 
rapid  example  which  I  have  seen  was  a  shopkeeper  aged  thirty- 
four.  He  was  perfectly  healthy  until  June  9,  1875.  He  was 
then  suddenly  seized  with  intense  thirst,  and  profuse  discharge 
of  highly  saccharine  urine,  and  died  on  June  18,  after  an  illness 
of  only  eight  days.  I  saw  another  case,  a  child  of  three  years, 
wdio  died  in  three  weeks.  Becquerel  mentions  the  case  of  a 
boy  of  nine  years  who  died  in  six  days.  On  the  other  hand, 
cases  sometimes  run  on  for  six,  eight,  or  ten  years.  The  follow^- 
ing  table  shows  the  duration  of  diabetes  in  100  fatal  cases, 
collected  by  Griesinger : 

Under      3  months       ........  1  case. 

Between  3  and    H  months '2  cases. 

"        6     "    12       " 13      " 

"         1     "      2  years 89      " 

"        2    "      3      " 20     " 

"        3     "      4     " 7      " 

"        4    "      5     " 2     " 

"         5    "      6      " 1      " 

"        6     "      7      " 2     "■ 

"        7     "      8      " 1      " 

Undetermined .         .         .  12      " 

The  progress  of  diabetes  is  usually  equable  and  continuous ; 
but  cases  are  met  with,  not  very  unfrequently,  in  which  the 
symptoms  intermit — the  saccharine  state  of  the  urine  ceasing 
and  recurring  at  intervals.  Dr.  Bence  Jones^  has  published  an 
account  of  several  such  cases  in  old  persons ;  and  I  have 
encountered  similar  ones  in  my  own  practice.  These  will  be 
again  noticed  among  the  milder  tj'pes  of  the  disease.  Girard 
records  an  example  of  intermittent  diabetes  in  a  girl  of  eighte^n.^ 

The  sjmiptoms  sometimes  begin  suddenly,  and  not  insidiously. 
Not  unfrequently  too,  the  symptoms  are  much  more  violent  in 
the  first  few  months  than  at  a  later  period,  wdien  the  disease  has 
become  confirmed.  "When  diabetes  has  alread}'  existed  two  or 
three  years  the  thirst  and  voracity  rarely  maintain  their  primi- 
tive intensit}".     This  change   from   a   more    acute   to   a   more 

1  Med.-Chir.  Trans.,  vol.  xxxvi.  ^  Union  Med.,  1855 


254  DIABETES    MELLITUS. 

chronic  state    must    not,    of    course,    be   mistaken    for   a   real 
improvement. 

Diabetes-  may  occasionally  terminate  in  complete  cure,  but 
the  majority  of  cases  end  fatally.  The  disease  only  exception- 
ally proves  fatal  through  its  own  intensity.  More  frequently 
one  of  the  complications  supervenes  and  carries  off  the  patient. 

COMPLICATIONS. 

The  most  common  and  formidable  compHcation  is  pulmonary 
tubercle,  which  affects  nearly  one-half  of  the  cases  protracted  to 
the  third  year.  The  pulmonary  disease  runs  the  course  of  rapid 
phthisis.  A  low  and  fatal  type  of  inflammation  is  also  liable  to 
arise  in  the  lungs,  pleura,  or  peritoneum.  In  every  tissue  of 
the  body  there  exists  a  tendency  to  asthenic  inflammation,  apt 
to  run  on  to  abscess,  difiJuse  suppuration,  sloughing,  phagedsenic 
ulceration,  or  gangrene. 

The  occurrence  of  boils  and  carbuncles  in  diabetic  patients 
has  long  been  known.  The  statement  of  Prout  that  sugar  is 
alwaj^s  present  in  the  urine  of  patients  sufl:ering  from  boils, 
is  certainly  incorrect.  Dr.  Goolden  mentions  the  case  of  a 
medical  man,  long  diabetic,  who  had  an  enormous  anthrax  on 
the  nucha,  which  compromised  his  life.  He  recovered,  however, 
from  the  anthrax,  and  with  its  disappearance  the  sugar  departed 
from  the  urine.  P.  Frank  cites  an  almost  similar  case.  Phil- 
lipeaux  and  Yulpian  ("  Gaz.  Hebd.,"  Dec.  6,  1861)  relate  an 
example  of  anthrax  in  a  hemiplegic  patient  who  was  not  pre- 
viously diabetic.  During  the  suppuration  of  the  anthrax  the 
urine  became  strongly  saccharine ;  but  ceased  to  be  so  when  the 
anthrax  cicatrized. 

Gangrene  of  the  lower  extremities,  resembling  gangrsena 
senilis,  has  been  several  times  observed  in  diabetes.  Two 
examples  have  come  under  my  observation  of  fatal  gangrene  of 
the  great  toe  in  diabetic  subjects.  One  was  a  man  of  seventy, 
who  had  been  diabetic  for  twelve  years.  No  pulsation  could  be 
felt  in  the  arteries  of  the  corresponding  limb  below  the  popliteal. 
The  other  was  sixty  years  of  age,  and  was  not  suspected  to  be 
diabetic  until  the  toe  became  gangrenous.  Sir  IT.  Marsh^  men- 
tions the  case  of  a  lady,  about  seventy  years  of  age,  sufl:ering 
from  diabetes  of  long  standing,  who  was  carried  off  suddenly 
with  gangrene  of  the  foot  and  leg.  On  examination  an  obstruc- 
tion was  found  in  the  iliac  artery.  Dr.  Colles  (quoted  by  Marsh) 
had  seen  two  similar  cases  of  obstructed  arteries,  and  fatal  gan- 
grene in  diabetes.  In  1845,  Carmichael  presented  to  the  Patho- 
logical Society  of  Dublin  two  cases  of  senile  gangrene  of  the 
lower  limbs  in  diabetic  patients.^     Marchal  de  Calvi  has  drawn 

1  Dublin  Quarterly,  1854.  »  Med.  Gaz.,  1846,  p.  110. 


COMPLICATIONS.  255 

attontioii  to  tlie  Bamc  suljijcct  Tnorc  recently,  and  ])ubli8hed  four 
new  cases.  Additional  cases  have  also  been  brought  forward  by 
liodgkin,  Landouzy,  Champouillon,  Billard,'  and  others. 

Defects  of  sight  in  connection  with  diabetes  have  of  late  years 
attracted  a  good  deal  of  attention.  They  consist  either  in  an 
enfeeblement  of  vision  (amblyopia),  or  cataract. 

Amblyofia  occurs,  according  to  Bouchardat,  in  about  a  fifth 
of  the  cases  of  diabetes.  Generally  speaking,  it  is  slight  in 
degree  and  temporary,  or  recurrent.  In  one  of  Griesinger's 
patients  the  amblyopia  ceased  when  a  flesh  diet  was  used,  bu^ 
it  was  succeeded,  shortly  after,  by  cataract.  Permanent  am- 
blyopia is  less  frequent;  it  occurs  only  in  advanced  cases,  and , 
is  a  sign  of  approaching  fatal  termination.  The  dimness  of 
sight  steadily  increases,  and  at  length  ends  in  total  blindness. 

Occasionally  the  amblyopia  may  be  accompanied  by  no 
ophthalmoscopic  signs.  In  some  cases  simple  atrophy  of  the 
optic  nerve  is  seen,  while  in  others  there  are  observed  hemor- 
rhages in  the  retina  with  consequent  retinitis.  Opacities  of  the 
vitreous  are  ver}'  common.^ 

Diabetic  cataract  was  first  noticed  in  this  country  by  Mr. 
France,  and  Lecorche  has  given  an  excellent  resume  of  what 
was  known  on  the  subject  up  to  1861.  It  occurs  generally 
in  inveterate  cases  of  lone:  standino;.  It  is  an  unfavorable  sisfn: 
and  death  follows  its  appearance  usually  in  a  few  months ;  but 
sometimes  patients  with  diabetic  cataract  survive  for  years.  The 
frequency  of  cataract  in  diabetes  has  been  estimated  very 
differently  by  different  authors.  Griesinger  observed  cataract 
in  three  out  of  his  own  seven  cases.  V.  Graefe  estimates  the 
proportion  as  one  in  five;  Bouchardat  as  one  in  thirty-eight. 
Garrod  had  not  encountered  cataract  in  any  of  the  large  number 
of  cases  of  diabetes  which  he  had  seen.  Out  of  fortj'-five  cases 
(written  in  1865)  which  I  have  treated,  only  one  had  cataract. 
Of  225  cases  collected  by  Griesinger,  cataract  occurred  in 
twenty. 

Diabetic  cataract  comes  on,  sometimes  without  previous 
defect  of  vision,  sometimes  after  one  or  more  attacks  of  tera- 
porarj'-  amblyopia;  sometimes  it  complicates  permanent  am- 
blyopia. It  generally  arises  after  the  diabetic  state  has  lasted 
eighteen  months  or  two  years ;  but  it  has  been  known  to  appear 
in  six  months.  Its  appearance  may  coincide  with  aggravation, 
amelioration,  or  stationary  condition  of  the  proper  diabetic 
symptoms.     Its  course  is  rapid ;  the  two  eyes  may  become  com- 

^  See  Charcot,  Gaz.  Hebd.,  Aug.  1861  ;  and  Dr.  Hodgkin,  Assoc.  Med.  Journ., 
1854.  The  whole  subject  is  treated  exhaustively  by  Marchal  de  Calvi  in  Eecher- 
ches  sur  les  Accidents  Diabetiques,  Paris,  1864.' 

^  For  further  information  on  this  subject,  reference  may  be  made  to  Dr.  Gower's. 
"  Medical  Ophthalmoscopy." 


256  DIABETES    MELLITUS. 

pletely  cataractous  in  a  few  days;  sometimes  it  is  developed 
more  slowly.  It  begins  in  one  eye — generally  the  right — but 
soon  involves  both.  In  the  case  which  I  observed,  a  woman, 
twenty-four  years  of  age,  had  been  diabetic  for  two  years  and  a 
half  Three  months  previously  the  left  eye  became  suddenly 
cataractous :  in  less  than  a  week  the  opacity  had  reached 
its  maximum.     The  right  eye  was  still  clear  and  vision  perfect. 

Cataract  in  diabetes  is  nearly  always  of  the  soft  kind;  but 
examples  of  hard  diabetic  cataracts  have  been  met  with  by 
V.  Graefe,  Guersant,  and  Sir  W.  Wilde. 

It  has  been  conceived  by  Weir  MitchelP  and  Dr.  Richardson^ 
that  diabetic  cataract  is  produced  by  physical  imbibition  into  the 
lens  of  the  saccharine  matter  of  the  aqueous  humor  of  the  eye. 
This  opinion  is  based  on  the  temporary  opacity  produced  in  the 
crystalline  lens  of  the  frog,  when  the  animal  is  immersed  in  a 
saccharine  solution,  or  when  a  similar  solution  is  injected  into 
the  cellular  tissue.  It  is  very  doubtful,  however,  whether  the 
two  conditions  are  really  pathologically  analogous.  Lecorche 
failed  to  produce  opacity  in  the  lens  of  rabbits  by  injecting 
syrup  into  the  eye.  Artificial  cataract  in  the  frog  speedily  dis- 
appears when  the  animal  is  removed  from  the  saccharine 
solution:  but  diabetic  cataract  is  permanent,  and  does  not 
disappear  when  amelioration  of  the  symptoms  takes  place. 
How,  on  the  imbibition  theory,  can  the  cases  be  explained, 
in  which  (as  in  the  instance  which  occurred  to  myself)  one  lens 
has  been  completely  opaque  for  months  while  its  fellow  still 
remains  perfectly  transparent  ?  How  also  should  its  occurrence 
be  (as  a  rule)  so  long  delayed,  and  arise  so  suddenly,  without 
any  corresponding  increase  in  the  quantity  of  sugar  in  the 
urine  ?  It  seems  more  probable  that  diabetic  cataract  is  one  of 
the  many  degenerations  of  a  low  inflammatory  type  so  common 
in  confirmed  diabetes. 

Hepp  failed  to  find  sugar  in  a  cataractous  lens  removed  from 
a  diabetic  patient.  Fisher  obtained  a  similarly  negative  result 
in  another  case.  But  Stoeber  found  sugar  in  a  lens  examined 
by  him.^ 

Operations  for  diabetic  cataract  generally  fail,  from  uncon- 
trollable suppuration  of  the  eyeball.  Sometimes,  however,  the 
operation  succeeds;  and  if  the  primary  complaint  be  stationary 
and  quite  uncomplicated,  operation  may  be  recommended  as  a 
possible  solace  to  the  remainder  of  life. 

Lecorche  has  described  endocarditis  as  a  complication  of 
diabetes.  It  occurs  in  the  later  stages  of  the  disease,  and  usually 
afi:ects  the  auricular  surface  of  the  mitral  valve.     It  is  ascribed 

^  American  Journ.  of  Med.  Sci.,  Jan.  1860. 

2  Brown-Sequard's  Journ.  de  Physiologie,  July,  1860. 

^Annalesd'  Oculistiques,  xlviii.  p.  192. 


COMPL]  CATIONS.  257 

to  the  irritation  of  the  cudocardiurii  by  the  sugar  contained  in 
the  blood/ 

Very  various  affections  of  the  nervous  system  may  arise  as  com- 
plications in  diabetes.  Neuralgias  are  very  common  ;  they  most 
frequently  affect  the  fifth  cranial  and  the  sciatic  nerves,  and  are 
in  many  cases  bilateral.^  AnsBsthesia  and  various  forms  of 
par?esthesia  have  been  observed.  The  affections  of  the  eye  have 
already  been  described.  Deafness,  too,  is  occasionally  met  with. 
Amongst  the  affections  of  the  motor  system,  we  find  cramps,  in 
a  few  cases  convulsions,  and  paralysis  of  different  parts.  The 
paralysis  may  appear  as  hemiplegia,  or  may  attack  single  groups 
of  muscles,  such  as  those  of  the  eye — then  producing  ptosis  or 
strabismus.''^  The  general  mental  state  in  diabetes  has  been 
already  mentioned  {see  p.  252).  Further  psychical  disturbances 
are  sometimes  met  with.  Legrand  du  Saulle  has  found  in 
various  cases,  melancholy,  suicidal  tendency,  apathy,  and  occa- 
sionally imbecility.*  Dr.  Pavy  also,  has  reported  a  case  of  tem- 
porary mania  occurring  in  the  course  of  diabetes  ("Med.  Times 
and  Gazette,"  1879,  ii.  p.  262). 

The  Coma  which  attacks  diabetic  patients  has  in  recent  years 
attracted  considerable  attention  from  clinical  and  pathological 
observers.  Although  this  complication  had  been  noted  pre- 
viously by  many,  yet  a  complete  description  was  first  given  by 
Kussmaul^  in  1874.  Since  that  time  numerous  cases  have  been 
recorded,  and  it  is  now  possible  to  classify  them  into  various 
groups  according  to  the  different  clinical  pictures  presented.  Dr. 
Dreschfeld,  in  a  paper  read  before  the  Manchester  Medical 
Society  in  1881,  analyzed  more  tban  50  cases,  and  showed  that 
they  might  be  divided  into  three  groups.^ 

In  the  cases  of  the  first  group,  the  patient  after  complaining 
for  a  short  time  of  headache,  or  of  pain  in  the  epigastrium,  with 
a  slight  nausea,  is  attacked  by  a  great  feeling  of  anxiety  or  by 
restlessness  and  some  delirium,  after  which  a  peculiar  dyspnoea 
sets  in.  The  dyspnoea  affects  both  the  inspiratory  and  expira- 
tory stages  of  respiration,  but  no  cause  can  be  found  for  it,  by 
examination  of  the  chest,  and  there  is  usually  no  cyanosis.  This 
form  of  dyspnoea  has  been  aptl}^  termed  by  Kussmaul  "  Air- 
hunger."  Comatose  symptoms  appear,  from  which  the  patient 
may  at  first  be  roused  by  shouting  in  his  ear,  but  gradually  the 

^  See  Brit.  Med.  Journ  ,  1882,  i.  p.  843.  (I  have  met  with  one  example  of  this 
form  of  endocarditis  in  the  post-mortem  room  of  the  Manchester  Eoyal  Infirmary. 
It  corresponded  entirely  with  the  description  given  above.     E.  M.) 

'^  Worms.     See  Lancet,  1878,  ii.  p.  708. 

^  See  ivoss,  Diseases  of  the  Nervous  System,  vol.  ii.  p.  933. 

*  Gazette  des  Hopitaux,  1877 

5  Deutsches  Arch.  f.  klin.  Medicin,  Bd.  xvi.  S.  1. 

^  See  Brit.  Med.  Journ.,  1881,  li  p.  710.  A  similar  classification  is  also, 
adopted  by  Frerichs  in  his  recent  treatise  on  Diabetes. 

17 


258  DIABETES    MELLITUS. 

coma  becomes  complete.  The  pulse  is  much  quickened  and  the 
temperature  is  lower  than  normal.  Convulsions  are  of  excep- 
tional occurrence.  The  state  of  the  pupils  varies,  but  com- 
monly they  are  dilated.  The  coma  generally  ends  in  death  within 
48  hours,  and  only  a  few  cases  have  been  known  to  recover. 

The  symptoms  of  the  second  group  of  cases  closely  resemble 
those  of  uraemia  from  kidney  disease.  The  dyspnoea  is  not 
so  well  marked  as  in  the  preceding  form.  The  patient  com- 
plains of  general  weakness,  becomes  drowsy,  lapses  into  a  state 
of  coma  with  low  temperature  and  small  pulse ;  and  soon  dies. 

The  third  form  shows  all  the  symptoms  of  acute  Alcoholic 
Intoxication.  The  patient  does  not  show  the  same  muscular 
weakness  as  is  observed  in  the  two  preceding  forms.  He  is 
attacked  suddenly  by  great  excitement,  staggering  gait,  and 
drunken  delirium.  Giadually  drowsiness  and  coma  develop  as 
in  the  other  forms  and  death  ensues. 

Certain  phenomena  are  common  to  all  three  forms.  During 
and  preceding  the  attack,  a  peculiar  sweet  smell,  likened  to  that 
of  chloroform,  is  perceived  in  the  breath.  The  urine  has  a 
similar  odor;  and  it  gives  the  so-called  "acetone  reaction" 
with  perchloride  of  iron — that  is,  when  a  solution  of  perchloride 
of  iron  is  added,  in  excess,  a  deep  red  color  is  produced,  almost 
like  that  of  port-wine.^  This  reaction  was  first  described  by 
Gerhardt.  The  urine,  during  the  attack,  generally  contains  less 
sugar  than  before  the  development  of  the  symptoms,  and  not 
uncommonly  shows  a  little  albumen. 

Coma  is  more  liable  to  occur  in  the  earlier  stages  of  diabetes 
a,nd  in  young  subjects.  It  is  especially  frequent  after  muscular 
exertion  and  after  the  first  adoption  of  a  diabetic  diet.  Con- 
stipation, which  is  common  in  all  diabetics,  seems  to  predispose 
to  the  development  of  coma. 

The  pathology  of  diabetic  coma  is  still  in  the  region  of  theory.  The 
various  views  which  are  held  to  explain  the  development  of  the  symp- 
toms may  be  shortly  summarized  as  follows : 

Kussmaul  formulated  the  view  that  it  was  due  to  the  presence  of 
acetone  in  the  blood.  The  same  substance  being,  as  he  believed,  the 
cause  of  the  peculiar  odor  of  the  breath,  and  of  the  characteristic  reac- 
tion of  the  urine  with  perchloride  of  iron.  He  experimented  by  giving 
acetone  to  animals,  but  only  after  very  large  doses  did  he  get  any  symp- 
toms, and  even  then,  although  he  believed  that  the  symptoms  were  those 
of  diabetic  coma,  they  have  since  been  shown  to  differ  from  it  in  essen- 
tial particulars.  Large  doses  of  acetone  given  to  man  produced  no 
effects.     Acetone  has  in  some  cases  of  diabetic  coma  been  absent  from 

1  Yon  Jaksch  has  shown  that  the  so-called  "  acetone  reaction  "  is  by  no  means 
confined  to  diabetic  urine.  He  has  found  it  in  various  febrile  disorders  and  in 
several  other  conditions.     (Zeitschr.  f.  Klin.  Med.,  Bd.  v.) 


COMJ'LJCATIONS.  259 

the  blood,  while  the  acetone  odor  of  the  breath  is  found  in  many  other 
conditions,  especially  in  digestive  disturbances,  in  tuberculosis,  and  in 
many  disorders  of  children,  when  no  coma  occurs. 

Dr.  Balthazar  Foster  and  Dr.  Saundby'  thought  it  prol)able  that  the 
acetone  present  in  the  blood  might  act  by  dissolving  the  red  blood- 
corpuscles.  In  one  case,  under  the  care  of  Dr.  Foster,  the  blood  was 
noticed  to  be  of  a  pale  lake  color,  and,  on  standing,  a  grayish  layer 
formed  on  the  top.  This  layer  was  composed  of  granular  material,  and 
did  not  dissolve  in  ether.  A  similar  appearance  was  produced  experi- 
mentally by  mixing  acetone  with  blood. 

Rupstein^  showed  that  free  acetone  did  not  exist  in  the  blood,  but 
that  it  was  produced  by  the  breaking  up  of  ethyl-diacetic  acid  into  ace- 
tone and  alcohol.  It  is  quite  possible  that  cases  of  the  third  group 
may  actually  be  due  to  what  they  resemble — acute  intoxication  with 
alcohol. 

Quincke^  pointed  out,  that  the  substance  contained  in  the  urine, 
resembles  acetic  ether,  in  its  reaction  with  ferric  chloride,  and  in  break- 
ing up  into  acetone  and  alcohol,  but  that  the  urine  does  not  smell  of 
acetic  ether,  and  does  not  yield  acetic  ether  on  shaking  with  ether.  He 
showed  also  that  if  acetic  ether  is  present,  it  is  combined  with  something 
which  is  neither  grape-sugar,  an  alkali,  nor  a  normal  constituent  of 
the  urine.  Rupstein  and  Salomon  were  unable  to  obtain  the  ferric 
chloride  reaction  from  the  condensed  breath.  Acetic  ether  was  also 
given  to  dogs,  without  producing  any  poisonous  effects.  Still  another 
substance  will  give  the  ferric  chloride  reaction  in  urine,  and  this  is 
diacetic  acid  or  aceto-acetic  acid.  Deichmiiller  and  Tollens'*  have 
asserted  that  this  is  the  substance  present  in  the  urine  of  diabetics. 
Brieger,  however,  was  again  unable  to  produce  poisonous  symptoms  in 
dogs  by  giving  this  substance. 

Quite  recently  Stadelmann^  has  found  an  acid  in  diabetic  urine  which 
is  probably  13  croton  acid,  and  has  suggested  that  diabetic  coma  might 
be  due  to  poisoning  by  this.  Against  this  view  is,  however,  the  fact  that 
Frerichs  (loc.  cit.)  has  found  the  alkalescence  of  the  blood  undiminished 
in  diabetes.  /?  croton  acid  was  also  found  to  be  practically  non- 
poisonous. 

The  blood  of  diabetics  has  been  often  observed  to  contain  excessive 
quantities  of  fat  (see  p.  263).  Professors  Sanders  and  Hamilton''  de- 
scribed in  1879  a  case  of  diabetic  coma,  in  which  large  quantities  of  fat 
were  found  in  the  blood  and  numerous  fat  emboli  were  seen  in  the  lungs. 
They  suggested  that  fat  emboli  in  the  lungs  and  brain  were  the  cause  of 
the  symptoms.  Similar  cases  have  been  described  by  Starr,^  Fitz,®  and 
by  Fraser  and  Logan.®     Dr.  Dreschfeld,  however,  was  unable  to  find  fat 

1  Brit.  Med.  Journ.,  1878,  vol.  i.  p.  78. 

2  Centralbl.  f.  Med.  Wissen.,  1874,  p.  865. 
■'  Berlin,  klin.  Wochensch.,  1880,  p.  1. 

■*  Annalen  der  Chemie,  Bd.  ccix.  p.  22.  Also,  Brit.  Med.  Journ.,  1882,  i. 
p.  665. 

°  Archiv  f.  exp.  Patliolos.,  Bd.  xvii.  p.  443. 

6  Edin.  Med.  Journ.,  July,  1879,  p.  47. 

''  New  York  Med.  Record,  vol.  xvii.  p.  477. 

*  Boston  Med.  and  Surg.  Journ.,  vol.  civ.  p.  124. 

9  Edin.  Med.  Journ.,  Sept.  1882. 


260  DIABETES    MELLITUS. 

emboli  in  four  cases  of  diabetic  coma,  although  the  blood  contained 
large  quantities  of  fat.  Dr.  Taylor^  obtained  a  similar  result  in  three 
cases.  "  Moreover,  fat  emboli  are  found  in  other  disorders  without  pro- 
ducing any  such  alarming  symptoms. 

Schmitz,^  of  ISTeuenahr,  propounded  the  view  that  the  fatty  heart,  so 
often  found  in  diabetics,  was  the  cause  of  the  comatose  symptoms. 
Teschemacher^  believes  that  a  lesion  of  the  sympathetic  may  be  present, 
which  might  cause  shock.  Various  other  views  have  been  propounded, 
such  as  that  the  symptoms  are  due  to  thickening  of  the  blood  from  the 
presence  of  excessive  amounts  of  sugar,  to  urremia,  to  cerebral  ansemia,. 
etc.,  but  none  of  these  has  received  any  support. 

Ebstein  has  described  a  necrosis  of  epithelium  as  occurring  in  diabetes 
in  various  glands,  and  amongst  others  in  the  kidney.''  There  it  is  seen 
that  the  epithelium  of  the  convoluted  tubes  and  of  Henle's  loops  was 
swollen  and  hyaline  in  character.  In  many  parts  the  cells  are  fatty, 
the  nuclei  are  indistinct  and  do  not  easily  take  up  coloring  matters,  and 
the  cells  are  sometimes  detached  from  the  wall  of  the  tubule.^  It  seems 
most  probable  that  this  kidney  lesion  may  cause  a  retention  in  the  blood 
of  various  poisonous  matters,  which  are  derivatives  of  sugar,  but  whose 
nature  is  as  yet  unknown. 

PATHOLOGY  AND  MOKBID  ANATOMY. 

Although  diabetes  is  a  frequently  fatal  disorder,  necrology  has 
thrown  but  an  uncertain  light  on  its  seat  and  nature. 

The  more  palpable  anatomical  changes  which  have  been  often 
found  in  the  lungs  and  elsewhere,  are  manifestly  not  due  to  the 
disease  itself,  but  to  some  of  its  numerous  complications.  Physio- 
logical data  would  lead  us  to  look  for  the  primary  seat  of  dia- 
betes in  the  liver  itself,  or  in  some  part  of  the  brain  or  nervous 
system  connected  with  the  liver. 

The  liver  has  certainly  not  yet  given  up  its  secret,  if  it  have 
any.  The  accounts  of  its  appearance,  after  death  from  diabetes, 
are  contradictory.  Its  size  is  usually  normal;  sometimes  it  is  a 
little  enlarged,  sometimes  a  little  atrophied.  In  some  cases  it  is 
congested,  in  others  the  reverse.  Occasionally,  it  contains  a 
good  deal  of  sugar — more  frequently,  none  at  all.  Dr.  Wilks 
believes  that  the  diabetic  liver  presents  differences  to  the  eye 
which  enable  it  to  be  distinguished  from  others:  it  is  firm, 
tough,  homogeneous  or  uniform  in  appearance,  and  dark  in 
color.^  But  other  descriptions  are  quite  at  variance  with  this. 
Griesinger  found  the  liver  granular  and  easily  torn  in  one  case; 

^  Guy's  Hosp.  Keports,  3d  series,  vol.  xxv.  p.  158. 

2  Berl.  klin.  Wochensch.,  1876,  p.  63. 

3  Berlin,  klin.  Wocliensch.,  1881,  p.  450. 

*  Deutsches  Arch.  f.  klin.  Medic,  Bd.  xxviii.  p.  143. 

^  (I  have  found  this  lesion  in  three  consecutive  cases  of  diabetic  coma,  which 
died  in  the  Manchester  Infirmary.     R.  M.) 
®  Pavy  on  Diabetes,  p.  140. 


PATHOLOGY    AND    MO.liJMD    ANATOMY.  261 

in  fourteen  others  the  livers  were  perfectly  normal.  Dr.  Dickin- 
son sees  in  the  livers  of  diul)etic  ])atients  evidence  of  long-con- 
tinued liyperiiemia,  ending  in  overgrowth  of  the  epithelimn  and 
fibrous  tissue. 

Microscopical  investigations  have  been  eciually  unsatisfactory. 
Forster  and  Griesinger  found  the  liver-cells  naturah  Beale^ 
and  Frerichs^  remarked  a  diminution  or  absence  of  fat.  Pavy 
found  the  fat  undiminished.  Stockvis  found  the  fat  undimin- 
ished, but  an  unusual  proliferation  of  the  hepatic  cells.  Ehr- 
licli^  has  found  excess  of  glycogen  in  the  interior  of  the  liver 
cells. 

Of  the  bile,  Dr.  Pavy  remarks,  that  in  nearly  all  the  cases  in 
which  he  has  specially  examined  it,  it  has  presented  a  striking 
appearance,  resembling  a  rhubarb  mixture,  and  depositing  a 
copious  sediment  consisting  of  columnar  epithelium,  and  yellow, 
amorphous,  granular-looking  matter. 

Prout  says  that  he  frequently  observed  a  gorged  condition  of 
the  veins  terminating  in  the  portal  system. 

Affections  of  the  pancreas  have  been  frequently  found  in 
diabetes,  and  especially  hardening  and.  atrophy  of  the  organ. 
The  latter  condition  has  been  especially  insisted  upon  b}^  Lan- 
cereaux.* 

The  researches  of  Bernard  on  artificial  glycosuria,  and  the 
large  number  of  recorded,  cases  of  diabetes  in  which  the  disease 
has  followed  or  coincided  with  disease  or  injuries  of  the  brain, 
have  directed  the  attention  of  pathologists  to  a  more  minute  ex- 
amination of  the  nervous  centres. 

The  floor  of  the  fourth  ventricle  has  been  examined  in  several 
instances.  Sometimes  it  has  been  found  quite  natural;  in  other 
cases  it  was  found  the  seat  of  serious  pathological  changes.  In 
1860,  Luys  brought  before  the  Societe  de  Biologic  an  example 
in  which  this  spot  was  softened,  highly  vascular,  and  of  an  un- 
natural brown  color.  The  nerve-cells  were  found  degenerated 
and  full  of  yellowish  granules.^  Monneret  followed  up  this  ob- 
servation with  another  in  which  similar  changes  were  encoun- 
tered in  an  earlier  stage.^  Tardieu  records  a  case  of  diabetes  in 
which  there  existed  slight  paralysis  of  the  left  side  for  three 
months:  the  diabetes  persisted  until  death  two  years  afterwards 
from  phthisis :  the  medulla  oblongata  was  found  congested  and 
of  a  dark  gray  color,'' 

In  his  work  on  diabetes,  Dr.  Dickinson  describes  the  changes 
in  the  nervous  system  found  by  him  in  eleven  fatal  cases.  A 
practised  and  careful  eye,  he  says,  will  often  detect  a  porosity  in 

1  Med.-Chir.  Kev.,  1853,  p.  226.  ^  cited  bv  Griesinger,  loc.  cit.  p.  34. 

3  See  Frericlis  on  Diabetes,  1884.  *  Bull,  de  I'Acad.  de  Med.,  1877. 

»  Bulletin  de  la  Soc.  de  Biol.,  1860.  ^  q.^^   (jes  Hop.,  Jan.  11,  1862. 

^  Med.  Times  and  Gaz.,  Feb.  1862.  See  also  above,  p.  259. 


262  DIABETES    MELLITUS. 

limited  patches  of  the  white  matter,  as  if  it  was  closely  beset 
with  pin-holes,  each  puncture  containing  a  vessel  much  smaller 
than  itself..  Under  the  microscope  these  excavations  become 
conspicuous  objects.  The  excavations  are  found  about  arteries 
or  in  positions  which  arteries  have  once  occupied.  They  are 
sometimes  globular,  and  at  their  maximum  such  as  would  lodge 
peas.  Often  they  are  elongated  and  narrow,  and  may  be  de- 
scribed as  tunnels  directed  by  the  course  of  the  vessels.  They 
are  caused  by  a  destruction  and  absorption  of  the  nervous  mat- 
ter along  the  course  of  the  arteries,  and  are,  at  least  in  some 
instances,  caused  by  an  escape  of  the  contents  of  the  vessel  into 
the  surrounding  tissues,  with  consequent  degeneration,  softening, 
and  removal  of  the  nervous  matter  which  has  been  permeated 
by  the  intrusion. 

"When  the  disease  has  proceeded  to  its  natural  end,  the  excava- 
tions are  widely  scattered  through  the  brain ;  numerous,  small, 
and  closely  set  in  the  white  matter  of  the  convolutions,  fewer 
and  larger  about  the  central  parts.  The  corpora  striata,  optic  " 
thalami,  pons,  medulla  and  cerebellum  are  the  chosen  seats  for 
the  largest  and  most  striking  holes.  The  white  matter  of  the 
convolutions  is  often  rendered  strikingly  cribriform,  in  patches, 
by  numerous  erosions.  More  than  fifty  have  been  found  in  a 
space  of  not  half  an  inch  square — minute,  but  distinctly  visible 
to  the  naked  eye.  Each  contains  a  vessel,  usually  an  artery, 
around  which  is  an  irregular  interval,  containing  crystals  of 
h?ematine  and  products  of  nervous  degeneration.  These  holes 
are  evidently  exaggerations  of  the  perivascular  spaces.  The 
cavities,  whatever  their  size  and  place,  are  much  the  same  in 
appearance  and  contents.  They  are  abruptly  bounded,  usually 
with  a  narrow  margin  of  disintegrated  nervous  tissue,  the  brain 
matter  outside  of  this  being  absolutely  natural.  According  to 
their  date,  they  contain  degenerate  remains  of  nerve  tissue, 
remnants  of  bloodvessels,  or  of  extruded  blood,  or  are  empty. 
The  products  of  nervous  degeneration  are  first  removed,  then 
for  awhile  the  cavity  contains  only  dilated  or  shrunken  and  obso- 
lete arteries,  with  areolar  tissue  derived  apparently  from  the 
perivascular  sheath,  and  crystals  of  hsematine.  Lastly  these  dis- 
appear also,  and  a  mere  vacuity  is  left.  The  changes  in  the 
cord  are  similar  to  those  in  the  brain,  but  less  declared. 

Dr.  Dickinson  regards  these  lesions  as  the  initial  pathological 
fact  of  ordinary  idiopathic  diabetes,  and  as  the  primary  cause  of 
glycosuria.^  Whether  these  observations,  and  the  deductions 
drawn  from  them,  will  stand  the  proof  of  controlling  inquiries, 
remains  to  be  seen.     They  have  not,  even  now,  been  allowed  to 

^  Dr.  Dickinson  seems  to  have  p;iven  up  the  claim  that  these  changes  are 
peculiar  to  diabetes.     See  Lancet,  1878,  i.  p.  117. 


PATHOLOGY    AND    MORBID    ANATOMY.  263 

pass  without  challenge.  Kiilz'  states  that  in  three  cases  of  fatal 
diabetes  exaniined  by  him  no  enlargement  of  the  perivascular 
canals  of  the  medulla  could  be  discovered,  neither  with  the 
naked  eye  nor  the  microscope.  The  same  author  cites  W,  Miiller 
as  having  carefidly  compared  the  medulla  in  three  diabetics  and 
in  two  cases  of  paralytic  dementia,  and  as  coming  to  the  con- 
clusion tliat  diabetes  may  exist  without  enlargement  of  the  peri- 
vascular canals,  and  that  enlargement  of  the  perivascular  canals 
may  exist  without  diabetes,  and,  consequently,  that  the  anatomi- 
cal changes  found  by  Dickinson  have  no  causal  connection  with 
diabetes.  Taylor  and  Goodhart^  have  also  been  unable  to  find 
these  appearances. 

Dr.  Dreschfeld  made  a  communication  on  this  subject  to  a 
meeting  of  the  Manchester  Medical  Society,  on  Dec.  1,  1875. 
He  had  examined  the  brains  of  two  fatal  cases  of  diabetes.  In 
both  these  cases  the  brain  and  medulla  were  most  carefully 
searched,  and  microscopical  sections  were  made  both  from  fresh 
and  hardened  preparations,  but  in  none  of  them  could  altera- 
tions in  the  perivascular  canals  be  discovered,  such  as  have  been 
described  by  Dr.  Dickinson.  Indeed  one  of  the  specimens  had 
been  used  by  Prof.  Gamgee  to  illustrate  before  his  class  the 
normal  histology  of  the  brain.  It  certainly  seems  strange,  if 
this  wide-spread  destruction  of  nervous  matter  really  occurs  in 
diabetes,  that  mental  aberration  and  paralytic  accidents  should 
usually  be  so  conspicuously  absent  from  the  clinical  history  of 
idiopathic  diabetes. 

Silver  and  Irvine^  have  described  hemorrhage  and  softening 
of  the  spinal  cord  in  the  cervical  and  upper  dorsal  regions,  in 
one  case. 

Lesions  of  the  pneumogastric  and  of  the  sympathetic  nerves 
have  also  been  found  in  some  cases  of  diabetes.  Harley  cites  a 
case  in  which  a  calcareous  tumor  as  large  as  a  hazel-nut  was 
found  pressing  on  the  right  vagus  in  the  chest.  Poniklo*  has 
described  an  overgrowth  of  fibrous  tissue  in  the  ganglia  of  the 
sympathetic. 

The  blood,  as  might  have  been  expected,  is  unnaturally  charged 
with  sugar  in  diabetes.  It  has  been  found  in  the  proportion  of 
from  0.3  to  0.5  per  cent.  From  the  blood,  sugar  finds  its  way 
into  all  the  tissues  and  fluids  of  the  body.  Sugar  has  been 
found  in  the  feces,  the  sweat,  the  humors  of  the  eye,  the  tears, 
the  saliva,  and  the  gastric  juice. 

In  many  cases  of  diabetes  the  blood  also  contains  a  large 
excess  of  fat.     Dr.  Gamgee,  in  one  case,  found  as  much  as  10.8 

1  Beitrage  z.  Path.  u.  Therap.  d.  Diab.  Mell.     Marburg,  1874,  p.  10. 

^  Guy's  Hospital  Reports,  vol.  xxii.  p.  415. 

3  Path.  Trans.,  vol.  xxix.  *  Lancet,  1878,  i. 


264  DIABETES    MELLITUS. 

per  1000 — the  normal  proportion  being  about  2  per  1000. 
(Gamgee's  "Physiological  Chemistry,"  vol.  i.  p.  172.) 

Of  the  secondary  lesions  or  complications,  those  found  in  the 
lungs  are  the  most  common.  Out  of  sixty-four  autopsies  collated 
by  Griesinger,  tubercles  were  found  in  the  lungs  in  thirty-one, 
or  nearly  one-half  Pavy  and  Wilks  believe  that  the  pulmonary 
mischief  is  not  always  genuine  phthisis,  even  when  it  runs  a 
closely  similar  course,  but  consists  in  a  chronic  inflammation 
leading  to  the  breaking  down  of  the  lung  tissue  and  the  forma- 
tion of  cavities. 

Pneumonic  consolidation  and  gangrene  of  the  lungs  have 
likewise  been  not  unfrequently  found.  Sometimes  (not  ahvays) 
gangrene  of  the  lungs  in  diabetes  is  not  accompanied  by  the 
characteristic  fetor  of  that  complaint. 

In  long-standing  cases,  the  kidneys  are  not  unfrequently  found 
seriously  altered.  Out  of  Griesinger's  sixty-four  autopsies  renal 
alterations  were  found  in  thirty-two.  In  seventeen  instances 
there  was  degeneration  resembling  some  form  of  Bright's  dis- 
ease, mostly  with  fatty  degeneration  of  the  renal  epithelium. 
Granular  atrophy  of  the  kidneys  was  never  found;  but  cysts, 
cicatrical  spots,  adhesions  of  the  tunica  propria,  and  pyelitis.  In 
five  cases  the  kidneys  were  markedly  hypersemic,  and  in  seven 
considerablj^  hypertrophied.  Prout  states  that  the  kidneys  of 
persons  dying  of  diabetes  assume  frequentlj^  a  peculiar  deep 
orange  tint  on  exposure  to  the  air.  Ehrlich  has  recently  de- 
scribed collections  of  glycogen  in  the  cells  of  the  kidney  espe- 
cially in  the  region  where  the  cortical  and  medullary  portions 
join.^ 

The  stomach  is  commonly  found  distended,  and  the  mucous 
membrane  thickened  and  softened. 


PHYSIOLOGICAL   AND   THEOEETICAL    CONSIDEKATIONS 
KELATING  TO  DIABETES. 

Much  light  has  been  thrown  on  the  pathology  of  diabetes  by  the 
observations  of  Bernard  and  others  on  the  presence  of  an  amyloid  sub- 
stance in  the  liver,  and  the  possibility  of  inducing  glycosuria  in  animals 
by  artificial  means.  A  resume  of  the  present  state  of  these  questions 
is  absolutely  necessary  to  the  comprehension  of  any  theoretical  view  of 
diabetes. 

Bernard  discovered  the  fundamental  fact,  that  the  liver  of  all  healthy 
animals  contains  a  large  quantity  of  a  substance  resembling  starch  or 
dextrine.  When  the  liver  of  an  animal  newly  killed  is  abandoned  to 
itself  in  a  warm  place,  it  speedily  becomes  charged  with  sugar  by  the 
conversion  of  a  portion  of  this  substance  into  glucose ;  and  when  the 
sugar  so  produced  is  washed  completely  out  by  a  stream  of  water,  the 

'  See  Frerichs,  loc,  cit. 


PHYSIOLOGICAL    GONSI  J;KK  ATI  O  XH  .  265 

organ  abandoned  to  itself  as  l)ef'ore,  becomes,  again  in  twenty-four  hours, 
abundantly  charged  with  sugar.  This  conversion  goes  on  until  all  the 
amyloid  substance  is  changed  into  sugar.  The  transformation  here  wit- 
nessed takes  place  by  the  action  of  a  peculiar  ferment  which  circulates 
in  the  blood. 

I  have  obtained  the  amyloid  substance  of  the  liver  (which  lias  re- 
ceived the  various  names  of  animal  or  hepatic  dextrine  for  starch j,  hepa- 
tine,  and  zooamylum)  in  the  greatest  purity  and  with  the  greatest  ease 
from  the  liver  of  the  oyster.  The  large  fawn-colored  mass,  which  con- 
stitutes the  delicacy  of  this  mollusk,  should  be  cut  out,  and  plunged  for 
a  few  minutes  into  boiling  water.  The  hardened  mass  is  then  pounded 
in  a  mortar,  mixed  with  a  small  quantity  of  water,  and  boiled  so  as  to 
form  a  decoction.  This  is  subsequently  filtered,  and  poured  into  five 
times  its  bulk  of  strong  alcohol  or  glacial  acetic  acid.  An  abundant 
precipitation  of  snow-white  flakes  is  produced.  This  is  the  amyloid  sub- 
stance.    It  is  collected  on  a  filter,  washed  with  alcohol  and  dried. 

When  pure,  hepatic  dextrine  is  a  white,  tasteless,  inodorous  body.  It 
dissolves  freely  in  water,  forming  an  opalescent  solution  like  skimmed 
milk.  It  contains  no  nitrogen  ;  its  formula  is  CjoH,oOio.  With  iodine 
it  behaves  like  vegetable  dextrine,  yielding  a  deep  wine-red  coloration. 
It  does  not  reduce  the  salts  of  copper,  nor  ferment  with  yeast ;  but  (like 
starch  and  dextrine)  it  is  speedily  converted  into  glucose  by  the  contact 
of  saliva,  pancreatic  juice,  or  diastase.  It  is  similarly  converted  by  the 
contact  of  fresh  blood,  which  has  no  effect  on  starch  and  dextrine.  This 
last  property  is  its  peculiar  characteristic. 

Schiff  has  satisfied  himself,  by  a  most  ingenious  set  of  experiments, 
that  he  has  detected  the  exact  situation  and  physical  condition  of  the 
amyloid  substance  in  the  liver.  He  found  it,  not  infiltrated  or  dissolved 
in  the  hepatic  tissue,  but  collected  into  separate  vesicles  or  granules  pre- 
cisely as  occurs  with  starch  in  the  vegetable  kingdom.  In  the  frog,  he 
found,  under  a  magnifying  power  of  600  diameters,  that  the  liver-cells, 
in  addition  to  one  or  two  round  nuclei  and  twelve  or  twenty  fat  globules, 
contained  an  immense  number  of  minute  pale  vesicles  varying  in  size 
from  YeVo  to  toV"o  o^  ^  ^i^®-  Within  these  vesicles  the  amyloid  sub- 
stance is  accumulated.  The  outer  membrane  (as  in  the  vegetable  starch- 
granule)  contains  nitrogen.  Nasse^  has  subsequently  detected  similar 
amyloid  vesicles  in  the  liver-cells  of  worm-blooded  animals.  They  differ 
from  most  of  their  vegetable  homologues  in  not  possessing  concentric 
markings,  and  in  not  yielding  a  blue  coloration  with  iodine.  I  have 
endeavored  to  verify  these  observations  in  the  liver  of  the  frog  and  the 
oyster,  but  without  success. 

Animal  dextrine  is  always  present  in  the  livers  of  all  the  healthy 
animals  hitherto  examined,  whether  living  on  vegetable  or  animal  food, 
or  fasting.  But  under  a  variety  of  diseased  and  unnatural  conditions  it 
quickly  disappears.  The  circumstances  preceding  death  from  disease, 
are  such  that  the  liver  scarcely  ever  contains  a  trace  of  amyloid  sub- 
stance when  examined  post-mortem. 

The  peculiar  ferment  of  the  liver-dextrine  exists  in  the  blood,  but  has 
not  yet  been  isolated.     It  is  not  liable  to  disappear  under  those  condi- 

-  Archiv  des  Yereins  far  gemeinscbaftl.  Arbeiten,  lY.  I.,  p.  97. 


266  DIABETES    MELLITUS. 

tions  of  disease  which  cause  the  hepatic  dextrine  to  vanish  so  quickly. 
Nevertheless,  it  is  sornetimes  absent.  Schiff  made  the  curious  discovery 
that  this  ferment  totally  disappears  from  frogs  during  the  second  half  of 
the  winter  and  the  early  spring  months.  This  occurs  as  a  regular  event 
in  the  annual  changes  which  these  batrachians  undergo.  During  this 
interval  the  liver  is  as  full  as  usual  of  amyloid  substance,  but  no  sponta- 
neous production  of  sugar  occurs  when  the  organ  is  abandoned  to  itself 
in  a  warm  place,  and  artificial  glycosuria  cannot  be  engendered  in  such 
animals.  When,  however,  the  blood  of  another  animal,  which  is  not  in 
this  peculiar  condition,  is  injected  into  the  bodies  of  winter  frogs,  or 
applied  to  their  livers,  the  usual  production  of  sugar  takes  place  rapidly. 
This  absence  of  a  ferment  has  not  been  noted,  as  a  regular  occurrence, 
in  any  warm-blooded  animals  ;  but  Dr.  Pavy  states  that  he  once  encoun- 
tered a  healthy  rabbit  in  this  condition. 

Great  divergence  of  opinion  prevails  as  to  the  destiny  of  the  liver- 
dextrine  during  healthy  life.  Many  physiologists  adhere  to  the  view  of 
Bernard,  and  believe  that  a  continual  conversion  of  this  substance  into 
sugar  is  going  on  in  the  liver,  and  that  a  quantity  of  sugar  is  being  con- 
stantly poured  into  the  hepatic  veins  and  carried  off  into  the  circulation.^ 
Dr.  Pavy,  on  the  other  hand,  contends  that  there  is  no  conversion  of 
hepatic  dextrine  into  sugar  during  healthy  life,  nor  any  continual  stream 
of  sugar  flowing  into  the  circulation  ;  and  that  when  such  conversion 
does  take  place,  it  is  an  abnormal  or  diseased  occurrence,  or  due  to  post- 
mortem changes. 

"  Instead  of  the  liver  being  essentially  a  sugar-forming,  it  is  a  sugar- 
assimilating  organ.  Its  'great  function  in  relation  to  sugar  is  to  prevent 
this  principle  reaching  the  circulation  to  any  material  extent."  (Pavy's 
Croonian  Lectures.) 

In  cold-blooded  animals,  the  view  of  Pavy  has  appeared  to  me  to  be 
the  correct  one.  I  have  repeatedly  tested  the  point  in  frogs  and  oysters, 
and  have  never  succeeded  in  detecting  a  trace  of  sugar  in  the  liver,  if 
the  organ  was  examined  before  the  possibility  of  any  post-mortem 
changes.  In  the  case  of  the  oyster,  the  experiment  is  a  very  easy  one. 
A  fresh  oyster  is  cut  in  half  with  a  pair  of  scissors,  in  such  a  way  that 
one  half  shall  drop  into  a  capsule  of  boiling  water ;  the  other  half  is 
laid  aside  in  a  warm  place.  The  latter  very  speedily  becomes  abund- 
antly saccharine  ;  but  in  the  former  the  ferment  has  been  rendered  inert 
by  the  heat,  and  not  a  particle  of  sugar  can  be  detected  in  it,  even  after 
being  long  kept  in  a  warm  place.  The  conditions  in  the  oyster's  liver 
are  precisely  similar  (as  far  as  is  known)  to  those  in  the  liver  of  a  warm- 
blooded animal.  An  abundance  of  amyloid  matter  and  the  ferment 
coexist  side  by  side  in  the  organ,  and  yet  no  reaction  takes  place  be- 
tween them,  and  no  sugar  is  produced,  so  long  as  the  normal  state  is 
maintained. 

A  similar  experiment  is  more  difficult  in  warm-blooded  animals,  be- 
cause it  is  impossible  to  proceed  with  the  same  celerity ;  yet  in  Dr.  Pavy's 
hands  the  results  obtained  were   fully  confirmatory  of  his  doctrine. 

^  Among  these  may  be  mentioned  Harley  (Proc.  Eoy.  Soc,  vol.  x.  p.  289)  ; 
Schmidt,  of  Dorpat  (Comptes  Eendus,  t.  xlix.  p.  63),  and  Lusk:  (New  York  Med. 
Journ.,  1870).     Dalton,  Treatise  on  Human  Physiology,  5th  ed.  p.  193. 


PHYSIOLOGICAL    CONSIDERATIONS.  2f'>7 

Bernard's  glycogenic  theory  rests  chiefly  on  the  fact  that  in  newly  killed 
animals  the  blood  of  the  hepatic  veins  has  heen  found  sensibly  richer  in 
sugar  than  that  of  the  body  generally.  Pavy  attributes  this  result  to 
rai)id  changes  which  take  place  during  the  performance  of  the  experi- 
ment. He  has  varied  the  proceeding  in  such  a  mannei-  as  to  avoid  these 
disturbances.  lie  catheterized  the  right  heart  by  introducing  a  tube 
along  the  jugular  vein.  In  this  way,  if  the  animal  remained  quiescent, 
the  blood  of  the  hepatic  veins  was  obtained  in  its  normal  state.  Hepatic 
blood  so  obtained,  was  found  to  contain  only  those  minute  traces  of  sugar 
which  exist  in  every  part  of  the  circulation. 

Dr.  Robert  McDonnell,^  in  an  admirable  series  of  researches,  lias  re- 
peated and  varied  the  experiments  of  Pavy,  and  obtained  results  which 
do  not  seem  to  admit  a  possibility  of  doubt  that  amyloid  substance  is  not 
converted  into  sugar  in  the  liver  during  healthy  life.  In  his  memoir 
on  the  functions  of  the  liver,'^  McDonnell  brings  forward  some  facts 
and  considerations  of  great  weight  in  support  of  his  view,  that  the  real 
destiny  of  the  liver-dextrine  is  to  unite  with  nitrogen  (set  free  by  the 
disassimilation  of  fibrine  and  a  portion  of  the  albumen  of  the  portal 
blood)  so  as  to  constitute  a  new  protein  compound  resembling  casein, 
which  is  being  constantly  poured  into  the  circulation  through  the 
hepatic  veins.^ 

Dr.  Pavy  appears  to  insist  too  absolutely  on  the  absence  of  any  unim- 
peachable evidence  of  the  disappearance  of  sugar  introduced  into  the 
blood,  except  by  its  removal  through  the  kidneys.  It  has  been  fully 
made  out  that  sugar  and  dextrine  may  be  injected  continuously  into  the 
blood  in  certain  small  quantities — that  is,  so  much  that  the  percentage 
of  them  in  the  blood  shall  never  rise  beyond  0.2  or  0.3 — without  pro- 
ducing saccharine  urine.^  What  becomes  of  sugar  so  introduced  is 
doubtful.  It  may  not  be  oxidized,  as  has  usually  been  believed,  into 
carbonic  acid  and  water;  perhaps  it  is  transformed  into  amyloid  sub- 
stance and  lodged  in  the  liver.  That  it  disappears  somehow  without 
escaping  with  the  urine  cannot  admit  of  doubt.  Some  experiments  of 
Schiff  appear  to  bear  decisively  on  this  point.  He  induced  artificial  dia- 
betes in  frogs  by  puncturing  the  spinal  cord ;  he  then  ligatured  portions 
of  the  liver,  so  that  the  discharge  of  sugar  into  the  circulation  was 
diminished  in  proportion  to  the  size  of  the  piece  of  liver  included  in  the 
ligature.  When  a  piece  equal  to  about  a  fifth  part  of  the  organ  was 
included  in  the  ligature,  sugar  was  still  poured  into  the  circulation,  but 
not  in  sufficient  quantity  to  produce  glycosuria.'' 

Artificial  Glycosuria  and  Diabetes. — We  are  led  to  believe, 
then,  on  the  evidence  above  adduced,  that  although  the  amyloid  matter 

^  See  Proceedings  of  the  Eoyal  Irish  Academy,  Feb.  13,  1860. 
2  Observations  on  the  Functions  of  the  Liver,  bj-  R.  jNIcDonnell,  M.D.     Dublin 
and  London,  1865. 

*  Pavy's  results  have  been  further  confirmed  by  Meissner  and  Jaeger,  and  by 
Schiff  and  Herzen.  The  whole  of  this  question  is  treated  at  length  in  the  2d  ed. 
of  Dr.  Pavy's  work  on  Diabetes. 

*  Schiff,  loc.  sit.  p.  1.S4. 

^  That  a  trace  of  sugar  exists  in  normal  blood  (even  in  flesh-fed  animals)  seems 
to  be  now  generally  admitted.  Bernard,  who  originally  taught  this  was  con- 
sumed in  the  lungs,  afterwards  believed  with  other  physiologists,  that  it  is  utilized 
in  the  nutrition  of  the  tissues  and  especially  of  the  muscles. 


268  DIABETES    MELLITUS. 

and  its  ferment  must  be  in  close  proximity  in  the  hepatic  tissue,  they  do 
not  come  into  actual  contact  and  react  upon  each  other  during  healthy 
life;  but  they  may  be  brought  into  conjunction  under  a  variety  of 
unnatural  conditions  induced  by  disease  or  injury;  and  physiologists 
are  able  to  bring  about  these  abnormal  conditions  at  will,  and  to  cause 
sugar  to  appear  in  the  urine. 

Artificial  glycosuria  may  be  produced  in  various  ways,  namely,  by 
cutting  or  puncturing  diverse  parts  of  the  nervous  centres  and  certain 
organic  nerves ;  by  impeding  respiration  ;  putting  animals  under  the 
influence  of  anaesthetics  and  tetanizing  substances ;  injecting  acid  sub- 
stances into  the  portal  veins;  and  thrusting  needles  into  the  liver. 

Most,  if  not  all,  of  these  injuries,  different  as  they  appear,  act  finally 
in  the  same  manner,  and  cause  dilatation  of  the  hepatic  bloodvessels, 
and  consequent  hyperaemia  of  the  organ.  This  dilatation  may  (conceiv- 
ably) be  brought  about  in  two  ways :  either  by  an  increased  action  of 
the  longitudinal  muscular  fibres  (dilating  muscles)  of  the  small  vessels^ 
— this  would  be  an  active  congestion — or  by  a  paralysis  of  the  circular 
fibres,  whereby  the  vessels  would  give  way  and  expand  before  the  pro- 
pulsive action  of  the  heart. 

The  contractile  tissue  of  the  hepatic  vessels,  like  that  of  the  vascular 
system  generally,  is  under  the  control  of  a  distinct  nerve-arrangement, 
with  a  local  centre  in  its  neighborhood  (probably  the  cseliac  ganglion), 
and  upward  pi"olongations  by  the  sympathetic  and  the  spinal  cord  into 
the  cerebral  centres.  The  separate  threads  of  this  communication  are, 
in  the  lower  parts  of  their  course,  placed  widely  apart ;  but  they 
approach  in  the  spinal  cord ;  and  in  the  floor  of  the  fourth  ventricle 
they  are  collected  into  a  close  bundle  before  their  final  dispersion  into 
the  cerebral  hemispheres. 

An  irritation  applied  to  any  part  of  this  nervous  communication  may 
cause  temporary  glycosuria ;  and  in  the  floor  of  the  fourth  ventricle 
even  the  puncture  of  a  needle,  if  it  be  made  exactly  at  the  right  spot 
(midway  between  the  origins  of  the  auditory  nerves),  is  sufiicient.  The 
difficulty  of  exactly  hitting  this  spot  renders  the  operation  somewhat 
uncertain,  except  on  condition  of  injuring  the  surrounding  parts  exten- 
sively; and  Schiff  found  it  preferalDle  to  pass  in  a  needle  and  destroy 
the  whole  thickness  of  the  cord  at  the  point  of  origin  of  the  brachial 
nerves.  This  operation  never  fails  to  produce  temporary  glycosuria.  In 
warm-blooded  animals,  the  urine  continues  saccharine  for  a  few  hours ; 
in  frogs,  about  four  days.  Schiff  gives  good  reasons  to  believe  that  gly- 
cosuria so  produced  is  caused  by  an  active  congestion  of  the  liver. 

The  permanent  diabetes,  with  which  practitioners  are  familiar  in  the 
human  subject,  appears,  on  the  contrary,  to  be  paralytic  in  its  nature, 
and  to  be  due  to  a  passive  congestion  of  the  liver  from  loss  of  contrac- 
tility in  the  circular  fibres  of  the  hepatic  vessels.  Schiff  succeeded  in 
inducing,  in  rats,  a  permanent  diabetes  which  may  be  looked  on  as  the 
true  counterpart  of  the  idiopathic  disease  in  man.  This  was  accom- 
plished by  operating  on  the  spinal  cord  at  a  lower  point.     He  passed  a 

^  See  Schiff,  loc.  cit.  p.  92.  See  also  a  paper  by  the  same  author,  Journ.  de 
I'Anat.  et  de  Phys.,  t.  iii.  369.  Schiff  states  that  cutting  the  sciatic  nerve,  and 
even  the  nerves  of  the  anterior  extremity,  causes  a  slightly  diabetic  state  in  rabbits. 


PHYSIOLOGICAL    CONSIDERATIONS.  269 

strong  needle  into  the  spinal  cord  (with  the  least  possible  injury  to  the 
surrounding  parts)  and  destroyed  it,  o[)posite  the  second  dorsal  vertebra. 
Rats  operated  on  in  this  way  lived,  provided  their  temperature  was  arti- 
ficially sustained,  for  seventeen  and  even  twenty  days,  and  continued 
diabetic  to  the  end.  Rabbits  sometimes  out-lived  this  operation  nine 
days,  and  continued  diabetic  to  the  last  day.  Animals  higher  in  the 
scale  than  rodents  do  not  survive  this  operation. 

Temporary  glycosuria  has  also  been  induced  by  impeding  respiration 
(Pavy);  by  poisoning  with  strychnia  and  woorali ;  by  thrusting  needles 
into  the  liver  (Schiff') ;  by  chloroform  and  ether  inhalations  in  warm- 
blooded animals  ;  in  frogs,  by  tying  the  afferent  veins  of  the  kidneys  so 
as  to  increase  the  flow  of  blood  through  the  liver  (SchiflT; ;  by  injecting 
stimulants  into  the  hepatic  veins  (Harley)  ;  by  painfully  stimulating  a 
sensory  nerve,  by  stimulating  the  central  end  of  the  divided  pneumo- 
gastric  or  of  the  depressor  nerve,  and  by  stimulating  the  first  dorsal  pair 
of  nerves  (Laffbnt). 

Dr.  Pavy  has  found  that  strongly  pronounced  glycosuria  is  produced 
in  dogs  by  injecting  arterial  blood  into  the  portal  vein.  This,  he  thinks, 
"  affords  an  explanation  of  the  glycosuria  which  follows  Bernard's  punc- 
ture of  the  fourth  ventricle  and  the  various  lesions  of  the  sympathetic. 
Without  any  new  agent  being  called  in,  sufficient  is  presented  in  the 
state  of  the  blood  to  account  for  the  production  of  sugar  that  occurs. 
By  a  vaso-motor  paralysis  affecting  the  vessels  of  the  chylo-poietic  vis- 
cera, the  blood  will  reach  the  portal  system  without  having  become 
dearterialized  in  its  natural  way ;  and  in  this  state  it  has  been  shown  to 
possess  the  pi'operty  of  acting  within  the  liver  in  such  a  manner  as 
to  determine  the  production  of  glvcosuria  "  ("  Proc.  Roy.  Soc.  "  June 
17,  1875). 

It  should  also  be  mentioned  that  the  introduction  of  large  quantities 
of  sugar  and  starch  by  the  digestive  organs  occasions  glycosuria — show- 
ing that  the  assimilating  power  of  the  liver  over  these  aliments  is  not 
unlimited.  Inuline  (which  replaces  starch  in  the  compositae)  induces 
slight  glycosuria,  even  when  partaken  of  in  comparatively  small  quan- 
tity (Schiff"). 

Bearing  these  physiological  data  in  mind,  we  shall  not  find  any  diffi- 
culty in  explaining  the  circumstances  under  wdiich  temporary  glycosuria 
occurs  in  the  human  subject  in  connection  with  various  injuries  and  dis- 
eases; and  we  obtain  some  dim  insight  into  the  true  pathology  of  clinical 
diabetes. 

Dr.  Pavy  applies  his  views  to  the  explanation  of  permanent  glyco- 
suria in  the  following  manner  :  He  urges  that  in  diabetes  there  is  a 
hyperpemia  of  the  abdominal  organs,  and  esiDecially  of  the  liver,  this 
being  probably  caused  by  some  affection  of  the  vaso-motor  mechanism. 
Such  a  hyperemia  would  cause  the  blood  flowing  through  the  liver  to 
be  more  highly  oxygenated  than  is  normal,  and  would,  therefore,  pro- 
duce glycosuria,  as  in  his  experimental  results. 

It  must  be  remembered,  in  searching  for  sugar  in  the  urine  of  persons 
who  present  the  alleged  conditions  of  glycosuria,  that  the  search  will  be 
in  vain  if  there  be  great  disturbance  of  the  general  system,  and  especi- 
ally if  there  be  fever  ;  for  the  amyloid  substance  speedily  disappears 
from  the  liver  under  these  circumstances,  and  consequently  no  sugar  can 


270  DIABETES    MELLITUS. 

appear  in  the  urine,  however  perfectly  all  the  other  conditions  for  its 
occurrence  exist.  This  is  doubtless  the  reason  of  the  many  contradic- 
tory results  of  bedside  observations  on  the  occurrence  of  saccharine 
urine.  I  have  repeatedly  examined  the  urine  of  patients  with  obstruc- 
tion in  the  chest  (emphysema,  etc.)  in  whom  there  existed  great  hyper- 
semia  of  the  liver,  without  finding  sugar ;  but  it  nearly  always  happens 
in  such  cases  that  the  general  well-being  of  the  patient  is  deeply  affected, 
or  that  there  is  positive  pyrexia.  From  what  has  been  said  above,  it  is 
important  to  remember  that  in  such  cases,  the  hypersemia  is  of  the 
venous  and  not  of  the  arterial  form. 

Although  we  appear  to  be  approaching  an  exact  knowledge  of  the 
pathogenetic  elements  of  glycosuria,  it  is  yet  manifestly  impossible,  in 
the  present  state  of  science,  to  frame  a  comprehensive  and  clear  theory 
of  diabetes.  It  would  seem  highly  probable  that  diabetes  consists  prox- 
imately in  some  disturbance  of  the  destiny  and  function  of  the  amyloid 
substance  of  the  liver.  But  this  disturbance  may  be  due  originally  to 
disease  far  away  from  the  liver  itself,  in  some  part  of  the  nervous  circle 
which  controls  this  function.  Occasionally,  as  in  traumatic  cases,  it  is 
possible  to  place  the  finger  on  the  primary  lesion ;  but  in  the  immense 
majority  of  cases  we  are  left  in  a  sea  of  conjecture.  Further  researches 
conducted  in  the  light  of  past  and  future  physiological  discoveries,  can 
alone  reduce  these  conjectures  to  order  and  certainty. 

DIAGNOSIS  AND  PROGNOSIS 

The  Diagnosis  of  diabetes  is  generally  a  very  simple  matter, 
when  attention  is  once  directed  to  the  urine — the  existence  of 
sugar  in  the  urine,  and  diuresis  being  the  only  points  to  be 
ascertained.  The  means  of  detecting  sugar  and  of  estimating 
its  quantity  have  already  been  fully  considered. 

Care  must  be  taken,  however,  not  to  conclude  too  rashly  that 
this  formidable  disease  exists,  from  the  mere  finding  of  sugar  in 
the  urine.  It  has  just  been  shown  that  the  urine  becomes  tem- 
porarily saccharine  under  certain  conditions  quite  apart  from 
genuine  diabetes.  Before  the  existence  of  diabetes  can  be  de- 
duced, it  must  be  ascertained  that  there  is  a  considerable 
quantity,  and  not  a  mere  trace,  of  sugar  in  urine;  secondly,  and 
especially,  that  its  appearance  is  not  temporary,  but  persistent; 
and  thirdly,  that  there  is  a  less  or  greater  increase  in  the  volume 
of  the  urine. 

A  more  recondite  diagnosis  than  this,  is  at  present  rarely 
possible  :  but  it  is  to  be  hoped  that  the  time  is  not  very  far  dis- 
tant when  we  shall  be  able  to  indicate  the  seat  of  the  initial 
lesion  in  each  case,  and  to  refer  it  to  a  cephalic,  spinal,  sym- 
pathetic, hepatic,  or  other  category,  as  the  symptoms  or  previous 
history  may  point  out. 

Peognosis. — The  general  prognosis  is  highly  unfavorable: 
the  large  majority  of  the  cases  terminate  fatally.     A  not  incon- 


PKOGNOSIH.  271 

siderable  number,  however,  recover  completely;  and  many  more 
attain  to  a  state  of  conditional  amelioration — tliat  is,  an  ame- 
lioration which  is  conditional  on  the  observance  of  a  certain  diet 
and  regimen. 

The  special  prognosis  depends  on  a  variety  of  circumstances, 
of  which  the  following  are  the  more  important.  The  younger 
the  patient  the  less  hope  of  ultimate  recovery.  All  the  cases 
under  twenty,  which  I  have  seen,  have  eventually  succumbed. 
In  persons  advanced  in  years,  the  appearance  and  persistence  of 
saccharine  urine  is  a  far  less  serious  aftair:  it  may  continue  for 
many  years  in  oscillating  degree  with  fair  preservation  of  health. 
It  is  a  curious  circumstance  that  diabetes  in  corpulent  persons 
is  very  markedly  less  formidable  than  in  those  of  spare  habit. 
Saccharine  urine  without  diuresis  is  far  less  serious  than  when 
the  urine  is  abundant.  Cceteris  paribus,  the  longer  the  disease 
has  existed,  the  more  unfavorable  the  prognosis;  cceteris  paiibus, 
also,  the  greater  the  general  severity  of  the  symptoms,  the  less 
is  the  hope  of  amendment.  The  ascertained  cause  of  the  dis- 
ease also  afiects  the  prognosis.  Cases  which  can  be  traced  to 
mental  anxiety  and  traumatic  lesions  appear  to  be  somewhat 
more  hopeful  than  those  for  which  no  tangible  cause  can  be  as- 
signed. 

The  presence  of  albumen  in  the  urine,  of  thoracic  or  intes- 
tinal complications,  are  fatal  signs.  The  existence  of  permanent 
amblyopia,  or  cataract,  is  a  very  unfavorable  indication.  Such 
cases  generally  terminate  fatally  within  six  or  twelve  months, 
and,  so  far  as  is  now  known,  alwa^^s  eventually;  that  is,  they 
are  essentially  incurable  cases,  though  some  of  them  survive 
many  years. 

The  results  of  treatment  furnish  important  data  for  esti- 
mating the  gravity  of  the  prognosis.  A  very  favorable  circum- 
stance is  the  disappearance  of  sugar  from  the  urine  when  saccha- 
rine and  starchy  matters  are  withdrawn  from  the  diet.  Even 
great  diminution  without  total  disappearance  of  sugar  is  a  hope- 
ful sign.  On  the  other  hand,  the  persistence  of  sugar  in  quantity 
on  a  purely  animal  diet  is  a  sign  that  the  disease  is  confirmed 
and  far  advanced.  A  moist  perspirable  skin,  a  fair  appetite,  a 
stationary  condition,  are  all  favorable  signs. 

It  must  be  remembered  that  when,  by  treatment,  the  disease 
has  been  brought  apparently  to  a  stand-still,  a  diabetic  patient 
still  holds  his  life  by  a  very  frail  tenure.  To  use  the  expression 
of  Dr.  Prout,  persons  with  confirmed  diabetes,  though  apparently 
in  fair  health,  live  as  it  were  on  the  brink  of  a  precipice.  A 
little  undue  exposure  to  wet  or  cold,  an  unusual  bodily  exertion 
— trifl.es  to  the  healthy — may  excite  inflammatory  complications 
which  prove  rapidly  fatal. 


272  DIABETES    MELLITUS. 


TKEATMENT. 

The  seat^nd  nature  of  the  primary  lesion  are,  as  we  have  seen, 
nearly  always  concealed ;  and  we  know  almost  nothing  of  what 
may  be  called  a  radical  treatment  of  diabetes.  But  the  more 
prominent  symptoms — thirst,  inordinate  appetite,  emaciation, 
and  the  copious  diuresis,  are  unquestionably  dependent,  in  great 
part,  on  the  accumulation  of  sugar  in  the  blood,  and  the  imperi- 
ous necessity  for  its  removal.  A  clear  indication  for  treatment, 
therefore,  is  to  diminish  this  accumulation.  In  our  ignorance 
of  any  direct  means  of  checking  the  formation  of  sugar  in  the 
body,  we  resort  to  the  indirect  method  of  withdrawing  sugar 
and  amylaceous  substances  (which  are  easily  converted  into 
sugar  in  the  primce  vice)  from  the  dietary.  We  endeavor  further 
to  combat  any  existing  disorders  of  the  skin,  stomach,  bowels, 
and  other  internal  organs,  and  to  allay  certain  troublesome  symp- 
toms which  arise  in  the  course  of  the  disease.  By  means  of  a 
regulated  diet,  clothing,  and  habits  of  life,  invaluable  help  can 
be  rendered  to  diabetic  patients:  sometimes  so  as  to  open  the 
way  to  perfect  recovery:  often,  nay  generally,  so  as  to  relieve 
suffering  and  prolong  life. 

Diet. — The  plan  to  be  pursued  is  to  withdraw  as  completely 
as  possible,  but  not  too  suddenly,  all  saccharine  and  amylaceous 
articles — the  chief  of  which  are  bread  and  potatoes — ^from  the 
diet,  and  to  replace  them  by  appropriate  substitutes  from  the 
vegetable  kingdom,  and  by  animal  food. 

It  is  well  known  that  human  life  can  be  sustained  in  perfect 
vigor  on  a  purely  animal  diet.  Ths  inhabitants  of  the  arctic 
regions  subsist  exclusively  on  the  flesh  and  blubber  of  seals,  fish, 
and  such  produce  as  the  chase  of  the  climate  affords.  The 
fur-hunters  of  British  America  exist  for  many  successive  months, 
leading  a  life  of  great  muscular  activity,  on  a  flesh  diet  alone. 
But  in  our  more  settled  communities  the  use  of  bread  and  pota- 
toes is  almost  a  second  nature,  and  deprivation  of  them  is,  to 
the  great  majority  of  individuals,  an  almost  unendurable  hard- 
ship. To  obviate  this  difficulty  several  substitutes  for  bread 
have  been  contrived  which  are  of  very  great  value  in  the  man- 
agement of  diabetes.^ 

In  the  choice  of  substances  from  the  animal  kingdom j  the 

1  Prof.  Cantani,  of  Naples,  advocates  a  more  extreme  degree  of  non-saccharine 
and  non-amylaceous  diet  than  any  previous  writer.  He  gives  his  patients  abso- 
lutely, nothing  but  flesh  and  fish — forbidding  even  eggs,  green  vegetables,  and 
milk.  In  the  way  of  beverages  he  forbids  all  wines,  beer,  tea,  and  coffee,  and 
allows  only  simple  water  or  water  with  a  slight  admixture  of  rectified  spirit,  or 
lactic  acid.  He  claims  for  this  rigorous  treatment  much  more  complete  success 
than  has  hitherto  been  attained  by  the  restricted  diet  as  ordinarily  prescribed. 
His  experience,  however,  is  limited  to  five  cases.     II  Morgagni,  1870. 


TREATMENT. 


273 


only  doubtful  or  forbidden  articles  are  milk,  honey,  and  liver. 
Butclicr'H  meat,  cheese,  butter,  fat  and  oil,  ])Oulti'y,  <(ame,  aggn, 
iislj,  may  be  used  freely  in  any  form.  Broths,  sou[)S,  and  jellies, 
(prepared  without  meal  or  sugar)  are  also  permissible  ad  lihitum. 
Milk,  which  contains  considerable  proportions  of  a  saccharine 
substance,  should,  as  far  as  possible,  be  replaced  by  cream. 
Milk,  however,  is  much  less  deleterious  to  a  diabetic  patient 
than  might  have  been  supposed.  In  a  girl  with  confirmed  dia- 
betes I  made  the  following  trial  of  the  effect  of  milk.  For  four 
weeks  she  was  fed  on  animal  flesh  and  bran  cakes;  during  the 
succeeding  four  weeks  three  pints  of  milk  daily  were  added  to 
this  diet;  and  for  three  weeks  subsequently,  the  milk  was  with- 
drawn. The  annexed  table  shows  the  exact  results  of  the  treat- 
ment. 


Meat  diet,  and  bran  1 
cakes  ;  for  four  weeks  / 

Meat  diet,  bran  cakes, 
and  three  pints  of 
milk  ;  for  four  weeks 

Meat  diet,  gluten  bread,  "| 
and  cabbage ;  for  V 
three  weeks  j 


Average  daily 

quantity  of 

urine. 

Average  quantity 

of  sugar 

daily  excreted. 

.      55  OZ. 

897  grains. 

.     49  OZ. 

1260  grains. 

.     41  OZ. 

1020  grains. 

Increase  of 
weight. 

5  lbs. 


5  lbs. 


7  lbs. 


The  patient  continued  to  gain  weight  and  to  improve  in  her 
general  condition  under  the  use  of  milk,  although  the  density 
of  the  urine  and  the  excretion  of  sugar  somewhat  increased.  A 
limited  supply  of  milk  may  therefore  be  allowed. 

Liver,  as  found  in  the  butcher's  shops,  contains  a  considerable 
quantity  of  sugar;  it  also  contains  amyloid  substance,  w^hich  is 
changed  into  sugar  by  the  saliva  and  pancreatic  juice.  Liver  is 
therefore  to  be  avoided  by  diabetic  patients.  The  edible  mol- 
lusks — oysters,  cockles,  mussels,  etc. — are  also  imjDroper,  on 
account  of  the  large  quantity  of  amyloid  substance  contained  in 
their  enormous  livers.  For  the  same  reason,  the  "pudding"'  of 
crabs  and  lobsters  is  objectionable. 

The  prohibited  articles  among  vegetables  are  much  more 
numerous  and  important,  and  the  substitutes  less  perfect  and 
more  difficult  to  find. 

The  oldest  substitute  for  bread  is  the  "bran  cake."  Thehusk 
or  bran  of  wheat  consists  of  lignin  and  an  albuminoid  substance, 
and  is  quite  devoid  of  starch.  When  this  is  washed  and  ground 
it  may  be  made  up  into  a  rude  imitation  of  bread  with  but 
and  eggs,  and  constitutes  a  valuable  addition  to  the  diet  of  a 
diabetic  patient.^ 

1  The  best  formula  for  bran  cakes  is  the  following,  supplied  by  Dr.  Camplin  : 
'■'■Formula  for  Bran  Cakes. — Take  a  sufficiert  quantity  (say  a  quart)  of  wheat 
bran,  boil  it  in  two  successive  waters  for  a  quarter  of  an  hour,  each  time  straining 

18 


274  DIABETES    MELLITUS. 

Another  important  substitute  is  Bouchardat's  "gluten  bread." 
This  is  prepared  by  washing  out  the  starch  from  wheaten  flour, 
and  working  up  the  remaining  gluten  into  loaves  and  cakes. 
This  bread  is  manufactured  on  a  large  scale  in  France,  with  the 
aid  of  powerful  machinery  for  inflating  the  dough  with  com- 
pressed air,  or  carbonic  acid  gas.  It  forms  a  light  and  elegant, 
and  by  no  means  unpalatable  bread.  Gluten  is  also  ground  down 
into  a  meal,  and  may  be  used  for  thickening  broths  and  making 
puddings.^  These  preparations  are  not  quite  free  from  starch; 
all  the  samples  examined  by  me  showed  an  intense  blue  colora- 
tion with  iodine. 

By  far  the  most  palatable  form  of  gluten  bread  is  that  pre- 
pared by  Mr.  Bonthron,  of  106  liegent  Street,  London.  He 
sends  it  out  in  the  form  of  small  buns,  which  eat  crisp,  and  keep 
about  a  fortnight.  Those  of  them  that  I  have  tested  were  nearly 
free  from  starch. 

Dr.  Pavy  has  introduced  rusks  and  biscuits  prepared  from  the 
starchless  meal  of  the  sweet  almond.^     These  are  more  expen- 

it  through  a  sieve,  then  wash  it  well  with  cold  water  (on  the  sieve),  until  the 
water  runs  off  perfectly  clear  ;  squeeze  the  bran  in  a  cloth  as  dry  as  you  can,  then 
spread  it  thinly  on  a  dish,  and  place  in  a  slow  oven  ;  if  put  in  at  night  let  it  re- 
main until  morning,  when,  if  perfectly  dry  and  crisp,  it  will  be  fit  for  grinding. 
The  bran  thus  prepared  must  be  ground  in  a  fine  mill  and  sifted  through  a  wire 
sieve  of  such  fineness  as  to  require  the  use  of  a  brush  to  pass  it  through  ;  that 
which  remains  in  the  sieve  must  be  ground  again  until  it  becomes  qviite  soft  and 
fine.  Take  of  this  bran  powder  3  oz.  (some  patients  use  4  oz.),  the  other  ingredi- 
ents as  follows — three  new-laid  eggs,  1^  oz.  (or  2  oz.  if  desired)  of  butter,  and 
about  half  a  pint  of  milk,  mix  the  eggs  with  a  little  of  the  milk,  and  warm  the 
butter  with  the  other  portion  ;  then  stir  the  whole  well  together,  adding  a  little 
nutmeg  and  ginger,  or  any  other  agreeable  spice.  Bake  in  small  tins  (pattipans), 
which  must  be  well  buttered,  in  a  rather  quick  oven  for  about  half  an  hour.  The 
cakes,  when  baked,  should  be  a  little  thicker  than  a  captain's  biscuit ;  they  may 
be  eaten  with  meat  or  cheese  for  breakfast,  dinner,  or  supper  ;  at  tea  they  require 
rather  a  free  allowance  of  butter,  or  may  be  eaten  with  cu7^d  or  any 'of  the  soft 
cheeses. 

"  It  is  important  that  the  above  directions  as  to  washing  and  drying  the  bran 
should  be  exactly  followed,  in  order  that  it  may  be  freed  from  starch,  and  rendered 
more  friable.  Mr.  White,  of  Holborn,  who  made  my  mill,  and  was  subsequently 
employed  by  others,  attempted  to  grind  the  bran  for  them,  and  failed,  from  not 
washing  and  drying  the  bran,  which,  in  its  common  state,  is  soft  and  not  easily 
reducible  to  fine  powder.  In  some  seasons  of  the  year,  or  if  the  cake  has  not  been 
well  prepared,  it  changes  more  rapidly  than  is  convenient.  This  may  be  pre- 
vented by  placing  the  cake  before  the  fire  for  five  or  ten  minutes  every  day." — 
(Camplin  on  Diabetes — Appendix.)  These  cakes  may  be  had  from  Blatchley,  362 
Oxford  Street,  London.  The  mills  for  grinding  the  bran  are  made  by  Gallop, 
119  Cheapside. 

A  diabetic  patient  of  mine  says  the  cakes  are  much  improved  by  using  seven 
instead  of  three  eggs.  The  addition  of  a  teaspooniul  of  bicarbonate  of  soda  is 
also  an  improvement. 

^  Gluten  bread  and  other  gluten  preparations  made  after  Bouchardat's  formula, 
are  supplied  by  Van  Abbott  &  Co.,  Howford  Buildings,  Fenchurch  Street, 
London.  They  may  also  be  had  of  Jewsbury  &  Brown,  Market  Street,  Man- 
chester. 

2  Almond  rusks  and  biscuits  are  supplied  by  Hill,  Bishopsgate  Street,  London. 


T  R  K  A  T  M  E  N  T  .  275 

sive  than  the  fbrogoiug;   but  i  have  found  that  ])atiei)ts  relished 
them  as  a  change. 

None  of  these  substitutes  is  as  palatable  as  ordinary  bread: 
but  they  are  of  great  service;  and  may  l)e  used  one  after  the 
other,  as  the  patient's  inclination  rrtay  direct.  When  none  of 
these  can  be  had,  or  when  the  patient  refuses  all  tliree,  as  is 
sometimes  the  case,  resource  may  be  had  to  "torrefied"  bread. 
Thin  slices  of  ordinary  bread  are  toasted  before  the  fire  until 
they  are  deeply  and  thoroughly  browned — almost  blackened. 
The  starch  and  gluten  are  in  great  part  destroyed  by  the  heat, 
but  the  hungering  diabetic  relishes  greatly  the  charred  remnants 
when  well  buttered  and  eaten  with  other  articles. 

Rice,  tapioca,  sago,  semola,  macaroni,  and  vermicelli,  all  con- 
tain great  abundance  of  starch,  and  are  therefore  inadmissible. 
Apples,  pears,  gcwseberries,  currants,  plums,  oranges,  and  all 
sweet  fruits,  are  likewise  pernicious  from  the  quantity  of  sugar 
which  they  contain. 

In  place  of  potatoes,  turnips,  carrots,  parsnips,  beans,  and 
peas — all  of  which  contain  starch  or  sugar — substitutes  may  be 
found  in  green  vegetables — cabbage,  endive,  spinach,  broccoli, 
Brussels  sprouts,  lettuce,  spring  onions,  watercress,  mustard  and 
garden  cress,  and  celery. 

There  does  not  seem  to  be  any  real  advantage  in  forcibly 
curtailing  beyond  a  moderate  degree,  the  fluids  taken  by  dia- 
betic patients.  The  volume  of  the  urine  and  the  separation  of 
sugar  may  be  temporarily  reduced  by  this  means,  but  the  gen- 
eral distress  increases,  owing  to  the  more  intense  impregnation 
of  the  blood  with  sugar.  Prout  recommends  that  all  fluids  be 
given  in  a  tepid  state,  as  they  thus  allay  the  craving  for  liquids 
more  effectually  than  when  taken  cold. 

In  the  way  of  beverages,  tea  and  coifee  (without  sugar)  may 
be  used.  Chocolate  made  with  gluten  meal,  and  soda  water, 
may  also  be  used.  The  free  use  of  wine  and  spirits,  which 
is  especially  recommended  by  liouchardat  as  a  part  of  the 
diabetic  regimen,  is  of  more  than  doubtful  propriety.  Exact 
observations  do  not  support  Bouchardat's  views,  which  are 
based  on  theoretical  grounds.  Griesinger  found  that  the  use  of 
red  wine,  to  the  extejnt  of  a  bottle  and  a  half  or  two  bottles  per 
day,  strengthened  with  two  ounces  of  rectified  spirit,  increased 
considerably  both  the  quantity  of  urine  and  the  excretion  of 
sugar.  In  a  second  observation  by  the  same  author,  the  use  of 
alcoholic  drinks  caused,  in  addition  to  the  above  effects,  a  copi- 
ous diaphoresis  of  saccharine  sweat.  The  observations  of  Gar- 
rod,  Camplin,  Rosenstein,  Siemssen,  and  Heller,  are  also  un- 
favorable to  the  free  use  of  beer,  wine,  and  spirits.  They  should 
therefore  be  used  sparingly.  The  best  are  those  which  are  most 
free  from  sugar,  namely,  dry  sherry,  claret,  bitter  ale,  brandy. 


276  DIABETES    MELLITUS. 

and  whiskey.    Those  to  be  avoided  are  port,  sweet  and  efferves- 
cent wines,  sweet  ales,  porter,  rum,  and  gin. 

Tlie  use  of  acid  drinks,  and  especially  dilute  phosphoric  acid, 
has  been  highly  spoken  of  in  some  quarters.  Griesinger  reports 
unfavorably  of  their  effects.  He  pushed  dilute  phosphoric  acid 
to  the  extent  of  an  ounce  daily.  At  first,  and  under  the  smaller 
doses,  the  patient  seemed  to  do  very  well ;  but  after  ten  days, 
and  with  the  full  quantity,  the  volume  of  the  urine  and  the  pro- 
portion of  sugar  slightly  increased,  and  the  general  state  of  the 
patient  grew  worse.  I  have  frequently  employed  bitartrate  of 
potash  water  for  the  purpose  of  allaying  thirst,  with  good  effect. 

The  patient  should  be  clad  from  head  to  foot  in  flannel,  in 
order  to  encourage  the  action  of  the  skin,  and  defend  the  patient 
from  the  chilly  sensations  so  common  in  this  complaint.  A  warm 
bath  once  or  twice  a  week  is  also  very  grateful  to  the  patient, 
and  abates  the  harsh,  arid  condition  of  the  skin. 

The  results  obtained  from  the  dietetic  treatment  differ  a  good 
deal,  according  to  the  intensity  of  the  disease,  and  the  length  of 
time  it  has  existed.  The  following  records  illustrate  the  vary- 
ing degrees  of  amendment  which  may  be  anticipated  in  con- 
firmed cases :  In  the  first  two  cases  the  patients  were  permanently 
cured.  The  third  and  fourth  cases  were  inveterate,  and,  strictly - 
speaking,  incurable ;  in  these  the  quantity  of  the  urine  was  re- 
stored (temporarily  at  least)  almost  to  its  natural  limits,  and  the 
patients  gained  flesh  and  strength  in  a  very  remarkable  degree; 
sugar,  however,  still  persisted  in  the  urine,  and  any  deviation 
from  the  prescribed  regimen  was  sufficient  to  reawaken  the 
diabetic  symptoms  in  full  intensity.  In  the  fifth  case,  not  much 
more  than  a  temporary  arrest  of  the  downward  course  was 
attained,  and  this  was  speedily  followed  by  a  resumption  of  the 
untoward  march  to  a  fatal  termination. 

Case  1. — C.  R.,  set.  39,  of  a  corpulent  habit,  came  under  my  care  in 
October,  1861.  The  urine  amounted  to  eight  pints  a  day;  specific 
gravity  1040 ;  it  contained  a  large  quantity  of  sugar.  He  had  lost 
much  weight,  but  was  still  in  full  flesh.  The  ordinary  symptoms  of 
diabetes  were  present  in  moderate  intensity.  C.  R.  had  been  dyspeptic 
for  about  fourteen  years,  though  his  habits  had  been,  in  every  respect, 
temperate.  He  underwent  the  operation  of  lithotomy  when  a  child. 
For  the  last  two  years  he  had  perceived  that  he  gradually  lost  flesh, 
had  an  unusual  thirst  and  frequent  desire  to  pass  water.  During  this 
period,  he  had  to  get  up  three  or  four  times  each  night  to  empty  the 
bladder.  Latterly  the  ankles  had  begun  to  swell.  Most  of  the  teeth 
were  carious,  and  the  gums  loose  and  spongy.  For  two  months  the 
patient  was  treated  as  an  out-patient  of  the  Royal  Infirmary,  and 
enjoined  to  avoid  saccharine  and  amylaceous  articles  of  food.  It  was 
found  that  the  treatment  was  carried  out  very  inefficiently;  he  was 
therefore  admitted  as  an  in-patient  on  December  4,  1861. 


TREATMENT.  277 

For  a  week,  he  was  abandoned  to  the  ordinary  mixed  diet  of  the 
hospital.  During  this  week  lie  voided  daily  on  an  average  160  ounces 
of  urine;  specific  gravity,  1085-1040;  mean  daily  excretion  of  sugar, 
5680  grains.  He  was  then  put  on  a  diet  of  animiil  suhstances,  with 
cabbage  and  bran  cakes.  In  the  week  succeeding  the  change  of  diet, 
the  mean  daily  discharge  of  urine  fell  to  60  ounces  ;  specific  gravity, 
1022-1026.  The  sugar  fell  on  the  third  day  to  VA  grains,  on  the 
fourth  to  116  grains,  and  at  the  end  of  the  week  to  48  grains.  In  the 
second  week  the  urine  fell  to  its  natural  volume  and  density,  and  the 
sugar  was  reduced  to  a  mere  trace.  This  trace  persisted  for  six  weeks, 
when  it  suddenly  disappeared.  The  patient  gained  weight  at  the  rate 
of  three  pounds  a  week.  He  was  then  made  an  out-patient,  and  directed 
to  continue  the  restricted  diet. 

A  trace  of  sugar  reappeared,  from  time  to  time,  for  seveval  months, 
but  ceased  altogether  in  about  eight  months.  He  gradually  resumed 
the  moderate  use  of  ordinary  bread,  and  came  to  show  himself  at  inter- 
vals. I  saw  him  last  in  February,  1865,  The  urine  was  found  per- 
fectly free  from  sugar,  and  the  general  health  and  embonpoint  were 
completely  restored. 

Case  2. — ^T.  H.,  a  very  stout,  florid-complexioned  man,  34  years  of 
age,  who  weighed,  when  in  health,  over  sixteen  stone,  came  under  my 
care  September  19,  1864.  He  stated  that  in  the  previous  July,  when 
the  weather  was  very  sultry,  he  perspired  very  freely,  and  drank  large 
quantities  of  cold  effervescing  beverages. 

From  this  period,  a  violent  thirst  and  frequent  desire  to  void  large 
quantities  of  urine,  tormented  him.  He  lost  weight  to  the  extent  of 
about  40  lbs.;  he  was  voraciously  hungry,  and  his  strength  gradually 
declined. 

When  first  seen  by  me,  the  daily  discharge  of  urine  amounted  to  eight 
pints ;  specific  gravity,  1048  ;  sugar,  7540  grains  per  day.  The  general 
symptoms  were  mild.  The  tongue  and  skin  were  moist,  the  teeth  sound, 
the  gums  only  slightly  spongy.  He  complained  of  incessant  thirst, 
inordinate  appetite,  pain  in  the  back,  and  feebleness. 

He  was  put  on  a  restricted  diet  on  September  22d,  and  observed  the 
directions  given  to  him  with  the  most  praiseworthy  strictness.  He  was 
allowed  bran  cakes,  butter,  fresh  meat,  eggs,  cabbage,  tea  and  coffee 
sweetened  with  glycerine  ad  libitum.  He  was  cut  off  from  potatoes  at 
once,  and,  after  two  days,  likewise  from  ordinary  bread,  and  limited 
entirely  to  the  articles  above  enumerated.  A  warm  bath  was  admin- 
istered every  evening,  and  a  pill  containing  half  a  grain  of  opium  and 
one  grain  of  sulphate  of  iron  was  given  three  times  a  day. 

On  the  third  day  great  improvement  had  taken  place.  The'  urine 
was  reduced  to  50  ounces;  specific  gravity,  1028  ;  sugar,  210  grains. 

For  two  days  the  patient's  condition  remained  in  every  respect  sta- 
tionary; but  on  September  28th  he  did  not  feel  so  well.  The  urine 
had  fallen  to  20  ounces,  and  the  sugar  to  a  very  small  quantity ;  the 
pulse  was  98,  tongue  furred,  and  a  degree  of  pyrexia  prevailed.  He 
sweated  profusely  after  the  baths ;  and  some  hemorrhoids,  to  which  he 
was  subject,  became  very  painful,  the  bowels  being  confined. 


278  DIABETES    MELLITUS. 

This  disturbance  was  attributed  partly  to  the  somewhat  too  sudden 
revolution  in  the  diet,  and  partly  to  the  constipating  effects  of  the  pills. 

On  September  29th  the  pills  were  withdrawn,  the  baths  were  admin- 
istered every  other  evening,  instead  of  daily,  a  little  ordinary  bread  was 
allowed,  a  dose  of  castor  oil  administered,  and  the  patient  directed  to 
keep  his  bed. 

In  a  few  days  this  disturbance  subsided,  and  the  restricted  diet  was 
again  rigidly  enforced.  Rapid  amendment  set  in  ;  the  urine  returned 
to  its  natural  quantity  and  density;  the  sugar  gradually  diminished, 
and  on  October  17th  it  had  entirely  disappeared  from  the  urine. 

The  restricted  diet  was  adhered  to  for  another  fortnight,  and  then  a 
gradual  return  to  the  use  of  ordinary  bread  was  permitted,  the  urine 
being  carefully  examined  for  sugar  from  time  to  time,  but  none  found. 

At  the  beginning  of  1865,  the  bran  cakes  were  discontinued ;  ordi- 
nary bread  was  allowed  freely,  and  a  small  portion  of  potatoes.  At  the 
end  of  January,  all  restrictions  on  the  diet  were  withdrawn.  The 
patient  had  now  reached  almost  his  original  weight  of  16  stone,  and  felt 
himself  in  every  respect  perfectly  well.  He  was  last  seen  on  July  25, 
1865.     The  urine  was  found  ]3erfectly  free  from  sugar. 

In  the  first  of  these  instances,  a  confirmed  but  mild  case  of 
diabetes,  of  two  years'  standing,  was  perfectly  and  permanently 
cured  by  the  dietetic  treatment  in  about  eight  months.  In  the 
second  instance,  diabetes  of  three  months'  standing  was  com- 
pletely cured  in  less  than  a  month.  Recoveries  so  complete  as 
these  are,  unfortunately,  rare.  The  two  following  are  examples 
of  the  conditional  amelioration,  which  may  be  commonly  attained, 
even  in  severe  cases  : 

Case  3. — E.  H.,  a  well-grown  girl  of  sixteen,  a  factory  hand,  had 
.been  diabetic  for  three  years.  She  was  admitted  into  the  Manchester 
Infirmary,  March  26,  1860. 

The  disease  was  uncomplicated,  and  exhibited  in  great  severity  the 
outward  signs  of  diabetes  in  an  advanced  stage.  There  was  a  harsh 
dry  skin  ;  a  tongue  like  a  piece  of  broiled  ham,  and  deeply  furrowed  ; 
abdominal  pains,  constant  drowsiness,  consuming  thirst,  gross  appetite, 
dry  scurfy  skin,  and  great  emaciation. 

For  a  fortnight  after  admission,  she  was  put  on  the  common  diet  of 
the  hospital,  which  includes  a  liberal  allowance  of  meat,  potatoes,  and 
bread.  The  state  of  the  urine,  during  the  last  six  days  of  this  fortnight, 
was  as  follows  :  Mean  daily  discharge,  210  ounces  ;  mean  daily  excretion 
of  sugar,  10,400  grains;  average  density,  1042.     Her  weight  was  80  lbs. 

The  diet  was  then  changed.  Milk  and  all  vegetable  compounds  were 
withdrawn  ;  instead,  she  was  allowed  an  unlimited  supply  of  eggs,  fresh 
meat,  and  beef-tea.  The  patient  did  not,  however,  observe  my  directions 
strictly,  but  obtained,  and  surreptitiously  consumed,  certain  quantities 
of  oranges,  sugar,  and  treacle-toffy.  Nevertheless,  a  remarkable  im- 
provement in  her  condition  took  place.  At  the  end  of  eleven  days,  the 
mean  results  since  the  change  of  diet  were  :  Daily  discharge  of  urine, 
70  ounces  ;  sugar,  1860  grains  ;  average  density,  1034.     Weight,  81  lbs. 


Avdl 

■iige  (liuly  i|Uiint.it,v 

I{;uige  of 

Sugar 

of  iirino. 

(li'iisity. 

(^iicli  (liiy. 

Ounces. 

(■jiraiiiH. 

First  week 

.     54 

1025-1033 

11  GO 

Second  week 

.     fi7 

1021-1031 

970 

Third  week 

.     51 

1022-1035 

870 

Fourth  week 

.     49 

1019-1035 

690 

Entire  period 

.     55 

1019-1035 

897 

TKEATMNE'J'.  279 

The  general  health  was  also  much  ameliorated  ;  the  skin  was  softer,  the 
tongue  less  fiery,  the  thirst  and  appetite  allayed. 

On  A[)ril  21st,  bran  cakes  were  added  to  the  animal  diet,  and  greatly 
relished  by  the  patient.  From  this  date  to  May  Kith — a  |)eriod  of  20 
days — no  further  change  was  made.  The  results  are  shown  in  the  fol- 
lowing table.  I  have  divided  the  period  into  weeks,  for  the  purpose  of 
displaying  the  gradual  progress: 

'  Wfiglit. 

11)8. 

81 
84 
85 
86 


With  this  increase  of  weight,  her  general  condition  had  improved ; 
the  tongue  had  become  pale  and  moist,  but  it  was  still  mapped  on  the 
surface,  and  unnaturally  smooth. 

On  the  I6th  of  May,  milk  was  added  to  the  previous  diet ;  the  results 
are  given  in  a  preceding  page  (see  p.  273).  On  June  12th,  milk  was 
again  withdrawn,  and  gluten  bread  substituted  for  bran  cakes.  Cab- 
bage was  also  allowed  with  dinner.  The  flow  of  urine  on  this  diet 
averaged  41  ounces,  and  the  sugar  1020  grains  per  day.  The  body- 
weight  went  on  increasing  to  98  lbs.  Her  general  condition  was  now, 
at  the  end  of  eleven  weeks  of  treatment,  such,  that  an  unprofessional 
person  would  have  pronounced  her  cured.  The  outward  signs  of  dia- 
betes had  disappeared ;  the  skin  was  restored  to  its  natural  softness ; 
the  thirst  and  appetite  were  no  longer  inordinate ;  the  flow  of  urine  was 
reduced  within  the  normal  compass.  The  patient  had  gained  IS  lbs.  in 
weight ;  she  slept  soundly,  had  neither  pain  nor  ache  ;  her  strength  was 
so  far  restored,  that  she  was  able  actively  to  assist  the  nurses  in  the  work 
of  the  wards.  She  came  from  a  distant  town,  and  her  history  after 
leaving  the  Infirmary  is  unknown  to  me. 

Case  4. — W.  A.,  a  factory  hand,  ajt.  30,  was  admitted  as  an  out- 
patient, October  12,  1859.  He  presented  the  usual  appearance  of 
diabetes  in  full  career.  The  disease  was  uncomplicated,  and  had  ex- 
isted about  a  year.  The  quantity  of  urine  varied  from  10  to  15  pints 
daily,  and  its  density  averaged  1044.  The  patient  was  directed  to 
observe  a  restricted  diet;  and  a  pill  containing  a  grain  of  opium,  with 
a  quarter  of  a  grain  of  sulphate  of  iron,  and  half  a  grain  of  quinine, 
was  ordered  three  times  a  day.  This  treatment  was  continued — the 
doses  of  opium  being  gradually  increased — for  seven  months.  A  marked 
improvement  took  place ;  the  diabetic  symptoms  abated  considerably ; 
the  tongue  became  moist ;  the  urine  fell  to  five  or  six  pints  daily,  with 
a  specific  gravity  of  1040.  The  sugar  averaged  4400  grains.  He 
gained  strength  and  some  weight,  and  was  able  to  resume  his  occupation 
for  a  time.  As  his  condition  appeared  stationary,  he  was  made  an  in- 
patient on  May  8,  1860.  On  his  admission,  all  medicines  were  discon- 
tinued, and  the  patient  was  allowed  the  mixed  diet  of  the  house.  The 
effect  of  this  change  was  a  sudden  reappearance  of  all  the  untoward 


280  DIABETES    MELLITUS. 

symptoms,  with  a  sense  of  great  debility,  and  an  alarming  cough.  The 
condition  of  the  urine  was  as  follows :  Daily  discharge  of  urine,  205 
ounces ;  sugar,  7400  grains  ;  average  density,  1042.  Three  days  of  this 
freedom  from  treatment  had  forced  him  to  keep  his  bed. 

I  now  gradually  withdrew  all  amylaceous  substances,  and  substituted 
meat,  fish,  eggs,  and  beef-tea.  He  was  also  allowed  eight  ounces  of 
brandy  daily.  After  the  change  was  completed,  the  diet  was  absolutely 
devoid  of  starch  and  sugar.  Under  this  diet,  the  urine  altered  greatly 
for  the  better.  During  the  first  week  of  the  restricted  diet,  the  daily 
discharge  of  urine  was  61  ounces  ;  daily  excretion  of  sugar,  928  grains  ; 
average  density,  1032.  The  general  symptoms  also  improved,  but  not 
in  proportion  to  the  amelioration  in  the  condition  of  the  urine. 

A  second  week  of  the  same  treatment  brought  down  the  urine  to : 
Daily  discharge,  56  ounces;  daily  excretion  of  sugar,  658  grains;  average 
density,  1028. 

I  was  now  met  with  the  difficulty  which  so  many  have  encountered  in 
pursuing  this  treatment ;  namely,  a  total  failure  of  the  appetite,  and 
consequent  alarming  depression  of  all  the  vital  powers.  To  obviate 
these  untoward  events,  the  patient  was  allowed  bran  bread  and  the  free 
use  of  green  vegetables— cabbage,  lettuce,  and  watercresses.  A  grain 
of  opium  was  also  given  three  times  a  day.  The  diet  was  therefore  still 
starchless,  and  almost  entirely  devoid  of  sugar.  Decided  amendment 
followed  this  change,  and  in  a  few  days  the  returning  strength  and 
cheerfulness  kept  pace  with  the  improved  appetite  and  increasing 
weight. 

During  the  remainder  of  his  stay  in  the  infirmary,  a  period  of  two 
months,  no  further  change  of  importance  was  made  in  the  diet  or  medi- 
cine. The  patient's  weight  on  admission  was  97  lbs.;  but  it  rapidly 
sank  in  the  first  few  days,  and  at  the  end  of  three  weeks  it  was  only 
91  lbs.  From  this  time  onward,  however,  the  weight  began  to  increase, 
and  it  went  up  gradually  to  105  lbs.,  which  point  it  had  reached  the 
week  of  his  discharge. 

The  state  of  the  urine  for  the  last  two  months  was  remarkably  con- 
stant. The  daily  discharge  varied  from  40  to  60  ounces ;  the  daily 
excretion  of  sugar,  from  800  to  1000  grains  ;  the  average  density,  from 
1030  to  1033. 

The  excretion  of  sugar  ruled  higher  than  when  the  diet  was  exclu- 
sively animal.  This  I  attributed  to  the  improved  appetite,  which 
enabled  the  patient  to  take  more  nourishment,  rather  than  to  any 
untoward  influence  exercised  by  the  green  vegetables. 

I  might  greatly  multiply  examples  of  this  class ;  but  it  will 
be  more  useful  to  illustrate  the  less  fortunate  results  for  which 
the  practitioner  must  also  be  prepared. 

Case  5. — E.  B.,  a  niece  of  the  patient  C.  R.,  who  made  so  good  a 
recovery,  was  admitted  into  the  Royal  Infirmary  in  December,  1862. 
She  had  been  diabetic  for  16  months  ;  and  suffered  from  excessive  thirst, 
voracious  appetite,  and  great  emaciation.  The  tongue  was  glazed,  skin 
harsh  and  dry.  There  was  no  complication.  The  urine  amounted  to 
15  pints  a  day,  and  contained  over  10,000  grains  of  sugar,  when  she 
lived  on  a  mixed  diet. 


TREATMENT.  281 

She  remained  in  hospital  two  montliH;  and  was  gradually  limited  to 
a  diet  of  animal  flesh,  witli  eggs,  cabbage,  and  bran  l)read.  On  this 
diet  she  slowly  gained  three  pounds  in  weight,  anrl  improved  sensibly  in 
her  general  health.  The  urine,  however,  never  fell  below  five  pints; 
usually  it  oscillated  between  seven  and  eight  pints,  with  a  specific  gravity 
ranging  from  lOoO  to  1040,  and  a  daily  excretion  of  sugar  of  4450  to 
7420  grains. 

After  leaving  the  Infirraary,  she  speedily  relapsed,  gradually  grew 
worse,  and  died  in  March,  1863,  in  the  Withington  Workhouse. 

Much  discredit  has  been  thrown  on  the  dietetic  treatment, 
by  a  slovenly  and  incomplete  manner  of  carrying  it  out.  It 
requires  most  vigilant  watching  to  keep  guard  against  the  ad- 
mission of  forbidden  articles.  The  patient's  own  craving  for 
them  is  often  too  much  for  his  resolution,  and  most  artful  de- 
ceits are  practised  on  the  medical  attendant.  This  is  especially 
the  case  at  the  beginning  of  the  treatment.  After  awhile,  the 
patient  perceives,  from  his  own  experience,  the  importance  of 
abstaining,  and  the  desire  for  the  forbidden  articles  diminishes 
very  notably  after  the  lapse  of  some  weeks.  Amylaceous  com- 
pounds, too,  are  often  unwittingly  administered  by  the  attend- 
ants. Starchy  matter  is  never  absent  from  the  cook's  hand ;  it 
enters,  in  one  guise  or  other,  into  almost  every  dish. 

Then  there  arises  the  other  difficulty — the  rejection  by  the 
stomach  of  the  restricted  diet.  This  difficulty  is,  perhaps,  made 
too  much  of.  A  skilful  selection  and  frequent  change  of  articles 
of  diet,  usually  suffice  to  reconcile  the  digestive  organs.  The 
field  of  selection  among  admissible  articles  is  so  wide  that,  in 
private  practice,  the  practitioner's  resources  are  almost  inex- 
haustible. Among  hospital  patients,  however,  the  embarrass- 
ments on  this  score  are  very  serious. 

There  are  cases  of  such  severity,  that  not  even  a  temporary 
amendment  can  be  obtained  by  the  dietetic  treatment.  I  have 
known  more  than  one  such  instance  in  children  under  ten  years 
of  age,  in  whom  the  disease  ran  a  rapid  course,  and  proved  fatal 
in  a  few  months.  There  are  also  a  certain  number  of  chronic 
cases  in  which  the  dietetic  treatment  proves  unsuitable,  and 
hastens  rather  than  retards  the  final  catastrophe.  These  are,  for 
the  most  part,  long-standing  cases — cases,  perhaps,  which  have 
been  beneiited  at  a  previous  epoch  by  that  treatment.  In  two  of 
my  Infirmary  patients,  who  were  readmitted  to  the  benefits  of 
the  charity  after  an  interval  of  several  months,  a  much  more 
decided  amelioration  followed  the  dietetic  treatment  during  the 
first  period  of  their  stay,  than  during  the  second. 

The  sugar-forming  vice  of  the  diabetic  s^'stem  appears  at  first 
(and  throughout  in  the  milder  cases)  confined  to  saccharine  and 
amylaceous  articles  of  food;    but  as  the  disease  becomes  in- 


282  DIABETES    MELLITUS. 

veterate,  the  assimilation  of  the  albuminous  principles  is  more 
and  more  affected,  until,  at  .length,  these  yield  sugar  almost  as 
readily  as  the  former.     Griesinger  found  in  a  case  of  this  kind, 
on  strict  flfesh  diet,  that  three-tifths  of  the  albuminous  materials 
reappeared  in  the  urine  as  sugar.     When  matters  have  come  to 
this  pass,  it  is  not  to  be  wondered  at,  that  the  patient  no  longer 
derives  benefit  from  a  restricted  diet,  which  he  can  only  use 
sparingly,  and  almost  with  disgust,  and  that  he  should,  on  the 
whole,"find  himself  in  a  better  position  when  abandoned  to  ordi- 
nary mixed  fare,  which  he  can  consume  in  abundance,  and  with 
relish.     Experience  is  imperative  on  this  point.     When  a  flesh 
diet,  judiciously  eked  out  by  appropriate  substitutes  for  bread 
and  potatoes,  fails  to  ameliorate  the  general  condition,  it  should 
not  be  too  obstinately  persisted  in  after  a  fair  trial.     The  practi- 
tioner should  give  way  first  with  regard  to  bread,  and  hold  out 
longest  against  potatoes.     ITo  inflexible  and  universal  rule  can 
be  laid  down  respecting  the  diet  of  diabetic  individuals,  under 
all  circumstances  and  in  all  stages  of  the  complaint.    Cases  will 
occur,  in  which  the  power  to  take  a  plentiful  supply  of  a  mixed 
diet,  more  than  compensates  for  the  increasing  thirst  and  freer 
discharge  of  urine  and  sugar.     I  have  also  noted  that  some  of 
the  milder  types  of  this  disease  in  which  saccharine  urine  is  un- 
accompanied with  diuresis,  are  made  worse  by  a  too  restricted 
diet.     (See  Appendix  to  this  chapter.) 

Dr.  Donkin^  recommends  another  mode  of  carrying  out  the 
animal  diet  treatment — namely,  by  putting  the  patient  on  a  diet 
exclusively  composed  of  skimmed  milk,  which  he  administers 
in  quantities  of  six  or  eight  pints  daily — persevering  rigidly 
with  the  treatment,  if  necessary,  for  ten  or  twelve  weeks.  I 
have  seen  several  patients  who  tried  this  severe  method.  Few 
of  them  could  tolerate  it  except  for  a  few  days — and  those  who 
continued  longer  were  rapidly  reduced.  Three  chronic  cases  I 
know  of,  in  which  the  treatment  was  obstiuately  persevered 
with,  ended  in  fatal  exhaustion.  One  of  them  had  been  under 
my  care  for  a  considerable  period,  and  the  patient  maintained  a 
fair  state  of  health  under  a  moderately  restricted  diet  and  the 
use  of  opium  —  three  months  of  the  skimmed  milk  treatment 
brought  the  case  to  a  fatal  termination. 

Medicinal  Substances  in  Diabetes  ;  Supplementary  Means. 
— Some  of  these  are  employed  under  the  impression  that  they 
possess  a  really  curative  power  in  this  disease ;  others  are  re- 
sorted to  simply  as  adjuvants,  to  combat  some  particular 
symptom.  ' 

The  inquiries  hitherto  made  on  the  supplementary  means^ 
medicinal  and  other — employed  in  the  treatment  of  diabetes^ 

1  On  the  Milk  Treatment  of  Diabetes  and  Bright's  Disease.     London,  1871. 


TREATMENT.  283 

arc  mostly  vitiated,  by  an  iii.sufHcieiit  separation  oftlioir  cfibcts, 
from  those  of  the  restricted  diet,  which  is  usually  conjoined 
therewith,  and  a,  want  of  attention  to  the  clinical  grouping  of 
the  cases.  A  number  of  remedies  have  been  extravagantly 
lauded  on  diverse  hands,  and  have  in  this  way  attained  an  ephe- 
meral reputation;  but,  when  tried  by  accurate  observers,  they 
liave  proved  to  be  absolutely  inert.  Unless  the  points  just  indi- 
cated are  kept  in  view,  only  misleading  conclusions  can  be  drawn 
from  any  inquiries  on  this  subject.  It  is  quite  possible,  that 
remedies  which  have  proved  powerless  in  inveterate  cases  may 
be  of  real  service  in  milder  examples  of  a  different  type,  or  in 
the  earlier  stages  of  the  disease.  A  complete  revision  of  the 
supplementary  means  of  treating  diabetes  is  loudly  called  for. 
It  may  be  taken  for  granted,  in  the  present  state  of  knowledge, 
that  the  general  basis  of  all  treatment  of  diabetes  must  be  the 
dietetic  restrictions  already  described.  Other  means  should  be 
studied  with  a  clear  understanding  of  their  supplementar}'  and 
subordinate  place. 

Opium. — This  narcotic  is  unquestionably  of  great  use  in  the 
treatment  of  diabetes — not  from  its  direct  influence  on  the 
course  of  the  disease,  but  from  its  anodyne  properties.  If  no 
restriction  be  placed  on  the  diet,  opium  in  doses  of  from  6  to  20 
grains  a  daj'  has  always,  in  my  experience,  had  the  power  of  re- 
ducing the  flow  of  urine  by  about  one-half;  that  is  to  say,  of 
bringing  it  down  to  five  or  eight  pints,  and  this  without  increas- 
ing its  densit3\  But,  notwithstanding  this  amelioration  in  the 
state  of  the  urine,  the  downward  progress  of  the  disease  is  not 
arrested;  and  the  effect  of  the  drug  seems  attributable  to  its 
deadening  influence  on  the  appetite,  rather  than  to  a  specific 
power  of  checking  the  formation  of  sugar.  When  opium  was 
given  to  patients  under  a  restricted  diet,  it  did  not  in  my  hands 
exhibit  the  least  power  of  lessening  the  flow  of  urine  or  the  ex- 
cretion of  sugar.  Its  value  depends  on  its  power  of  inducing 
sleep,  and  of  allaying  the  dolorous  sensations  and  irritability 
which  constantly  torment  diabetic  patients.^ 

There  is  a  great  tolerance  of  opium  in  confirmed  diabetes. 
Doses  of  2,  3,  and  5  grains,  three  times  a  day,  are  generally 
borne  without  the  production  of  any  appreciable  narcotism. 

Dr.  Pavy  prefers  codeia  to  opium.  He  finds  that  this  alkaloid 
yields  all  the  good  eflects  of  the  crude  drug  without  some  of  its 
disadvantages.  He  gives  it  in  gradually  increasing  doses,  from 
a  quarter  of  a  grain  to  two  grains  three  times  a  day.  Other  ob- 
servers have  also  recommended  codeia,  but  I  cannot  say  that  my 
experience  altogether  justifies  this  preference. 

Alkalies. — Alkaline  substances  have  been  specially  recom- 
mended by  Miahle,  on  account  of  their  supposed  power  of  favor- 

^  See  the  author's  paper — Brit.  Med.  Journ.,  1860. 


284  DIABETES    MELLITUS. 

ing  the  oxidation  and  destruction  of  sugar  in  the  blood.  These 
theoretical  views  are  now  overthrown  In  two  of  my  patients, 
I  made  a  trial  of  full  doses  of  the  bicarbonate  of  potash.  One 
of  them  w'as  on  a  mixed  ordinary  diet,  and  the  disorder  was  far 
advanced.  The  urine  was  rendered  alkaline  for  ten  days  with- 
out in  any  way  altering  the  excretion  of  sugar,  or  the  general 
condition.  In  the  second  case,  the  patient  was  on  a  restricted 
diet.  She  took  for  a  fortnight  320  grains  of  the  bicarbonate 
daily,  in  divided  doses;  the  urine  was  thereby  rendered  freely 
alkaline.  During  the  week  preceding  the  alkaline  treatment, 
1160  grains  of  sugar  were  excreted  daily.  In  the  first  week  of 
the  alkaline  treatment  970  grains  a  day  were  separated,  and  in 
the  second  week  870  grains.  In  the  week  following  the  with- 
drawal of  the  alkali,  the  sugar  amounted  to  690.  This  observa- 
tion tends  to  show  that  the  alkali  had  no  appreciable  influence 
on  the  excretion  of  sugar.  I  have  not  encountered  any  difficulty 
in  rendering  the  urine  alkaline  in  diabetes,  as  Dr.  Pavy  seems 
to  have  done.^ 

Rennet  and  Pepsine  have  been  vaunted  in  such  terms  of  confi- 
dence, as  to  raise  hopes  which  are  not  destined  to  be  realized. 
The  most  remarkable  results,  obtained  from  rennet,  are  those 
published  by  Dr.  James  Gray.  He  states  that  of  twenty-seven 
persons  treated  seven  recovered.  This  is  an  example  of  most 
rare  success,  and  it  is  to  be  regretted  that  the  cases  are  not  re- 
ported with  that  exactitude  and  detail  which  are  desirable  on 
such  debatable  ground.  In  all  of  them  a  rigid  adherence  to 
animal  diet  and  bran  bread  was  insisted  on;  and  it  seems  more 
than  probable  that  the  amendment  in  each  case  was  due  to  the 
restricted  diet  rather  than  to  the  rennet.  Dr.  Nelson,  of  Birm- 
ingham, extols  the  same  remed3^  His  cases  do  not  seem  to  have 
been  severe  ones;  and  the  diet  was  regulated  in  at  least  some 
of  them.  The  reports  are  much  more  imperfect  than  those  of 
Dr.  Gray. 

I  gave  rennet  a  resolute  trial  in  one  confirmed  case.  It  was 
prepared  in  the  manner  recommended  by  Dr.  Gray,  and  given 
in  doses  of  two  tablespoonfuls  three  times  a  day.  The  patient 
took  it  for  more  than  two  months,  conjoined  with  a  rigidly  re- 
stricted diet.  During  this  period  he  improved,  and  gained  5  lbs. 
in  weight.  But  he  was  improving  just  as  rapidly  before  he 
began  the  rennet,  and  the  daily  excretion  of  sugar  had  not  in 
the  least  diminished  during  its  use.     Griesinger,  in  two  cases 

1  The  alkaline  and  ammoniacal  phosphates  and  the  carbonate  of  ammonia  have 
again  been  tried  bv  Basham  and  Pavj%  and  the  citrate  of  soda  by  Guyot.  See 
Brit.  Med.  Journ",  1869,  i.  323;  and  ibid.,  p.  590;  and  Syd.  Soc.  Year  Book, 
1865-6,  70.  Recently  the  use  of  ammonia  in  the  form  of  carbonate  and  acetate 
has  been  strongly  recommended  in  diabetes.  (Adamkiewicz,  Pfliiger's  Archiv., 
1879,  p.  160.)     The  evidence  in  its  favor  is  as  yet,  however,  scanty. 


TJiKATMENT.  285 

accurately  observed,  found  even  a  sliglit  iiicrea.se  of  sugar  during 
the  use  of  rennet.  Other  trustworthy  reports  are  equally  un- 
favorable. 

Parkes'  and  Leu])uscher^  ibund  ])(',|)sine  useless. 

I  conceived  that  it  was  worth  a  trial,  whether  some  of  the 
substances  which  act  powerfully  on  the  nervous  system,  might 
not  exercise  a  beneficial  effect  in  diabetes.  With  this  view%  I 
exhibited  strychnia  and  belladonna,  in  gradually  increasing 
doses,  until  their  physiological  effects  began  to  be  perceived. 
But  not  the  slightest  influence  on  the  excretion  of  sugar  could 
be  discovered  during  their  use. 

Among  the  more  recent  remedies  employed  in  diabetes  may 
be  mentioned  arsenic,^  iodine,  bromide  of  potassium,*  picric 
acid,  and  Calabar  bean.  The  last  three  I  have  tried  and  found 
useless.  The  evidence  in  favor  of  the  first  two  is  too  slender  to 
excite  much  hope.  I  have  tried  both  peroxide  of  hydrogen  and 
ozonic  ether,  only  to  find  that  the  hopes  held  out  with  respect 
to  them  were  altogether  delusive.^  Salicylate  of  soda  has  been 
used  by  several  physicians,  who  have  reported  very  good  results 
from  its  administration. 

I  have  given  lactic  acid,  as  recommended  by  Cantani,  repeat- 
edly and  resolutely,  without  seeing  the  slightest  advantage  from 
its  use. 

Independently  of  so-called  specific  remedies,  there  is  a  large 
field  for  the  skilful  use  of  adjuvant  means,  employed  simply  for 
their  ordinary  therapeutical  effects.  The  obstinate  constipation 
which  commonly  prevails  in  diabetes,  must  be  corrected  bv  a 
regulated  use  of  castor  oil,  seidlitz  powders,  or  the  ordinary 
rhubarb  and  magnesia  mixture.  Anodynes  are  called  for  to 
subdue  pain,  nervous  exhaustion,  restlessness,  and  insomnia. 
Dyspeptic  symptoms  are  to  be  combated  by  alkahue  tonics:  and 
for  this  purpose  I  know  of  no  better  combination  than  the  bi- 
carbonate of  potash  in  infusion  of  calumba,  with  hydrocyanic 
acid.  The  poverty  of  the  blood  and  the  progressive  emaciation 
are  best  combated  by  long  courses  of  iron  and  cod-liver  oil.  I 
have  already  spoken  of  a  solution  of  bitartrate  of  potash,  as  the 
best  means  of  directly  allaying  the  thirst.  When  the  cravino- 
for  food,  and  sense  of  sinking  at  the  epigastrium  are  trouble- 
some, a  pill  containing  two  or  three  grains  of  assafoetida,  ad- 

1  On  the  Composition  of  the  Urine,  p.  356,  note. 

•'  Arch.  f.  Path.  Anat.,  Bd.  xvni.  119. 

3  Bulletin  de  Therap.,  1870,  xlvi.  519  ;  Berlin.  Klin.  Wochensch.,  'So.  12, 1869  ; 
O.  Kees,  Lancet,  1864,  ii.  436  ;  and  Leube.,  Archiv  Gen.,  1870,  p.  602. 

'1  Austin  Flint,  Amer.  Journ.  of  Med.  Sci.,  1870,  282;  and  Begbie,  Edin.  Med. 
Journ.,  xii.  487. 

^  Moleschott  has  recently  recommended  iodoform,  and  has  obtained  gcod  re- 
sults from  its  use.     (Wiener.  Med.  Wochensch.  No.  17,  1882.) 


286  DIABETES    MELLITUS. 

ministered  twice  or  thrice  a  day,  often  gives  most  striking- 
relief. 

Diabetic  patients  often  reap  considerable  benefit  from  change 
of  air,  and  a  sojourn  at  watering-places.  The  Bristol  Hotwells, 
Vichy,  and  Carlsbad  waters  have  obtained  some  celebrity  for 
their  utility  in  diabetes.  Dr.  Murrell  has  recommended  Bethesda 
water.  In  milder  cases,  sea-bathing  may  be  recommended  in 
moderation  in  the  hot  season  of  the  year.^ 

Saccharine  Treatment  of  Diabetes. — Piorry  conceived  the 
odd  idea  that  the  main  evils  of  diabetes  depended  on  the  loss  of 
sugar  through  the  kidnej'S,  and  that,  by  compensating  this  loss 
by  administering  sugar  internally,  these  evils  could  be  overcome. 
Dr.  W.  Budd,  of  Bristol,  followed  up  Piorry's  lead,  and  admin- 
istered 5  to  8  ounces  of  sugar  and  4  ounces  of  honey  to  two 
diabetic  patients,  with  great  benefit.  Ordinary  mixed  diet  (in- 
cluding potatoes)  was  conjoined.  These  results  provoked  new 
trials  of  this  treatment  by  Dr.  Burd,  of  Shrewsbury,  Dr.  Sloane, 
of  Leicester,  Dr.  Bence  Jones,  and  Griesinger,  but  with  results 
so  decidedly  unfavorable  as  to  leave  no  doubt  of  the  inutility  of 
the  practice.  A  full  resiime  of  the  results  of  the  saccharine  treat- 
ment of  diabetes  may  be  found  in  a  paper  by  the  author  in  the 
''Brit.  Med.  Journ."'for  November,  1860. 


APPENDIX. 

Milder  Types  of  Diabetes. 

The  cases  brought  together  under  this  heading  are  somewhat 
miscellaneous;  and  they  do  not  present  those  marks  of  uni- 
formity, which  are  required  to  constitute  a  homogeneous  patho- 
logical group.  Thej'  are  separated  from  classical  diabetes  by 
certain  broad  distinctions  of  clinical  importance;  but  they  ex- 
hibit anions  themselves  certain  disaa^reements  which  make  it 
evident  that  they  represent  more  than  one  type  of  disease. 

From  ordinary  or  classical  diabetes,  these  milder  types  are 
distinguished  by  all  or  some  of  the  following  signs:  Absence  of 
a  fixed  tendency  to  a  fatal  termination;  absence,  or  only  mod- 
erate degree  of  thirst,  voracity,  and  emaciation ;  slight  or  tem- 
porary increase  in  the  quantity  of  urine;  transitory  duration; 
amenability  to  treatment;  slight,  moderate,  or  intermittent 
glycosuria. 

'  Bouchardat  speaks  in  high  terms  of  enforced  exercise  and  gymnastics  for 
diabetic  patients.     See  Annuaire  de  Therap.,  1865,  p.  291. 


M1LI>KK    TYJ'ES.  287 

The  greater  number  of  these  cases  fall  within  one  or  other  of 
the  three  following  groups,  to  each  of  which  illustrative  exam- 
ples are  appended : 

Group  I. — Urine  persistently  saccharine;  density  10-30  to 
1043;  diuresis  absent,  or  very  moderate;  no  excessive  thirst  or 
appetite;  moderate  conservation  of  strength  and  flesh;  stationary 
condition. 

Case  1. — Mr.  B.,  a  manufacturer,  set.  45,  thin  but  not  markedly  ema- 
ciated, able  to  attend  to  his  business,  consulted  me  May  14,  1861.  His 
health  had  been  feeble  for  six  months.  He  complained  of  weakness,  loss 
of  appetite,  and  restlessness.  The  urine  had  never  exceeded  four  pints, 
and  usually  did  not  exceed  three  pints  in  the  twenty-four  hours.  The 
specimen  sent  to  me  for  analysis  had  a  density  of  1042,  and  contained 
7.2  per  cent,  of  sugar.  There  was  no  inordinate  appetite  or  thirst ;  the 
skin  was  moist.  The  patient  had  tried  a  diet  composed  of  animal  flesh 
and  green  vegetables,  but  had  been  unable  to  adhere  thereto  on  account 
of  the  total  failure  of  the  appetite. 

During  the  last  four  years  I  have  seen  this  patient  several  times.  His 
condition  continues  unchanged,  both  as  to  the  general  health  and  the 
state  of  the  urine.  He  is  still  a  valetudinarian,  but  goes  about  his 
business,  and  observes  a  diet,  onjy  restricted  with  respect  to  the  use  of 
potatoes. 

Case  2. — Mr.  F.,  get.  50,  formerly  engaged  in  business.  He  consulted 
me  in  November,  1862,  and  stated  that  he  had  been  ailing  about  three 
years,  suffering  from  indigestion,  lowness  of  spirits,  and  loss  of  strength. 
A  twelvemonth  before  sugar  had  been  detected  in  the  urine.  The  urine 
had  not  at  any  time  exceeded  three  pints  in  the  twenty-four  hours.  He 
has  never  been  troubled  with  thirst ;  the  skin  is  usually  moist ;  there  has 
been  slight  emaciation.  He  has  tried  a  restricted  diet  without  any 
benefit. 

Two  specimens  of  urine  were  handed  to  me  for  analysis ;  one  on 
November  20,  1862,  and  the  other  on  April  22,  1863.  The  former  con- 
tained 7.7  per  cent,  of  sugar,  and  the  latter  (which  had  a  specific  gravity 
of  1039)  6.3  per  cent.  The  daily  quantity  at  both  dates  was  three  pints. 
The  disorder  in  this  instance  appears  to  have  arisen  from  worry  and 
anxiety  connected  with  business ;  but  for  a  period  of  two  years  after 
giving  up  business  he  remained  in  statu  quo,  no  treatment  appearing  to 
have  any  beneficial  result.  Recently  he  has  been  in  much  better  health, 
has  recovered  his  weight,  strength,  and  cheerfulness,  and  believes  him- 
self thoroughly  rid  of  his  complaint;  and  yet,  the  urine  has  now 
(February  23,  1865)  a  specific  gravity  of  1035,  and  contains  5.7'  per 
cent,  of  sugar.  In  the  autumn  of  1870  I  was  called  to  see  this  patient 
again.  The  sugar  had  now  for  a  long  time  disappeared  from  the  urine 
and  was  replaced  by  albumen.  He  was  suffering  from  general  anasarca, 
and  all  the  other  signs  of  chronic  Bright's  disease — of  which  he  died  in 
December,  1870. 

Case  3. — Dr.  Latham^  relates  a  case  resembling  these  in  most  respects. 
The  patient  was  a  gentleman,  set.  40,  well  known  in  the  profession  of  the 

1  Latham  on  Diabetes,  p.  147. 


288  DIABETES    MELLITUS. 

law.  The  urine  at  no  time  exceeded  a  quart,  but  it  was  so  sweet  "  that 
it  might  easily  have  been  mistaken  for  syrup."  The  dietetic  treatment 
was  resolutely  tried  without  any  good  effect :  he  died  with  cough,  colli- 
quative sweats,  and  other  signs  of  phthisis. 

Group  II. — Glycosuria,  temporary  or  intermittent;  thirst  and 
diuresis  moderate,  or  none;  little  emaciation  and  loss  of  strength; 
the  complaint  depending  on  mental  anxiety,  blows  on  the  head, 
or  concussion  of  the  spine,  and  terminating  in  complete  re- 
covery. 

Case  4. — A  gentleman,  set.  46,  engaged  in  business,  consulted  me  on 
March  23,  1862.  He  had  suffered  from  slight,  recurrent,  dyspeptic 
symptoms  for  more  than  a  year,  together  with  numerous  nervous  pheno- 
mena and  loss  of  rest.  During  this  period  he  had  undergone  great 
mental  stress  in  connection  with  the  responsibilities  of  a  large  manufac- 
turing concern.  On  two  occasions  he  had  been  seized  with  some  kind 
of  fit,  which,  from  the  description  given,  appeared  to  be  a  bastard 
epilepsy.  In  one  of  these  he  had  fallen  from  his  horse ;  but  there  was 
no  direct  injury  to  the  head.  At  my  request  a  specimen  of  urine  was 
sent  for  examination.  Its  specific  gravity  was  1035,  and  it  contained 
5.2  per  cent,  of  sugar ;  no  albumen  or  other  abnormal  ingredient  was 
present.  The  daily  quantity  did  not  exceed  three  pints.  He  was  put 
on  a  moderately  restricted  diet,  and  recommended  to  make  arrangements 
which  would  relieve  him  of  a  large  portion  of  his  responsibilities.  He 
continued  under  my  observation  for  six  months.  The  sugar  disappeared 
in  about  six  weeks,  except  a  trace,  which  also  vanished  at  the  end  of 
four  months.     His  health  is  now  (July,  1865)  perfectly  restored. 

One  of  the  most  singular  instances  of  glycosuria,  persisting 
for  several  months,  unaccompanied  with  any  of  the  sj^mptoms 
of  true  diabetes,  is  related  by  Griesinger  (loc.  cit.  p.  51). 

Case  5. — A  medical  student  had,  during  a  course  of  chemical  instruc- 
tion, in  the  year  18 — ,  often  examined  his  urine,  and  found  it  in  every 
respect  normal.  He  spent  the  summer  of  the  succeeding  year  in  Switzer- 
land, and  underwent  a  number  of  wettings  on  botanical  excursions. 
Some  months  later,  while  in  perfect  health,  the  appearance  of  the  urine 
attracted  his  attention.  On  examination  it  gave  an  abundant  sugar 
reaction  with  Trommer's  test.  He  now  examined  the  urine  daily,  and 
found  the  density  to  vary  between  1022  and  1027.  The  glycosuria  per- 
sisted throughout  the  following  winter,  during  which  he  continued  to 
reside  in  the  same  moist  and  foggy  locality.     In  the  succeeding  spring, 

Herr returned  from  Switzerland,  and,  being  much  occupied,  had 

no  longer  any  time  to  bestow  on  his  diabetes ;  and  when,  in  the  course 
of  the  ensuing  summer,  he  examined  the  urine  again,  he  found  it  totally 
free  from  sugar,  nor  has  a  trace  been  found  in  it  since.  During  the 
entire  period  that  the  urine  contained  sugar,  he  did  not  experience  a 
single  one  of  the  known  symptoms  of  diabetes. 


MILDEK    TYPES.  289 

Group  III. — Glycosuria  in  persons  advanced  in  years;  of  full 
habit;  moderate  conservation  of  flesh  and  strength;  moderate 
diuresis;  moderate  amount  of  sugar;  abundance  of  uric  acid 
deposits;  often  gout;  sugar  sometimes  present  for  years,  vary- 
ing greatly  in  quantity,  sometimes  intermitting — termination 
variable. 

Dr.  Bence  Jones  has  published  an  account  of  a  number  of 
cases  of  this  class.^  Of  twenty-nine  cases  of  glycosuria,  ob- 
served by  him  in  the  preceding  three  years,  eleven  were  above 
sixty  years  of  age,  and  six  of  these  were  above  seventy.  He 
supplies  the  following  analysis  of  these  eleven  cases: 

In  2,  the  disease  was  intermitting. 

In  6,  the  quantity  of  urine  was  scarcely,  if  at  all,  increased. 

In  1,  the  quantity  was  increased,  but  the  disease  had  probably 
existed  for  sixteen  years. 

In  1,  the  urine  was  albuminous,  and  the  diabetic  symptoms 
were  very  slight. 

In  1  (about  seventy-four  years  of  age),  the  disease  existed  in 
its  intensity. 

In  all  cases  save  one,  the  disease  was  of  exceedingly  mild 
character. 

Man}^  cases  of  this  kind  have  come  under  my  notice,  of  which 
the  two  following  examples  may  serve  for  illustrations : 

Case  6. — Mr.  A,,  a  surgeon,  set.  60,  a  tall,  stout  man,  of  powerful 
frame,  consulted  me  June  11,  1863.  He  had  noticed  for  the  last  four 
mouths  an  undue  frequency  of  micturition,  with  a  certain  languor  un- 
usual to  him,  of  which,  however,  he  thought  little,  until  the  copiousness 
of  the  urine  excited  his  suspicions,  and  induced  him  to  test  it  for  sugar. 
This  led  to  the  detection  of  his  complaint.     He  had  lost  some  flesh. 

When  I  examined  him,  he  had  a  ruddy  complexion  and  an  appearance 
of  health  ;  the  appetite  was  moderate ;  thirst  somewhat  troublesome ;  skin 
moist ;  he  went  about  his  usual  business — being  in  extensive  practice  in  a 
rural  district — with  scarcely  more  fatigue  than  ordinary.  The  teeth  were 
extensively  decayed.  The  urine  amounted  to  five  or  six  pints  daily. 
A  specimen  carefully  collected  for  twelve  hours  was  sent  to  me  for 
examination.  It  amounted  to  68  ounces;  specific  gravity,  1034;  it  de- 
posited uric  acid  copiously,  and  contained  6  per  cent,  of  sugar,  which 
indicated  a  total  of  1800  grains  in  half  a  day. 

Mr.  A,  was  gradually  put  on  a  restricted  diet,  with  gluten  bread.  In 
a  week,  the  urine  of  twelve  hours  had  come  down  to  45  ounces ;  specific 
gravity,  1035  ;  percentage  of  sugar,  6.1 ;  sugar  voided  in  twelve  hours, 
1190  grains. 

Four  weeks  later,  the  urine  of  twelve  hours  had  diminished  to  37 
ounces ;  specific  gravity,  1028  ;  sugar,  4  per  cent. ;  quantity  voided  in 
twelve  hours,  673  grains.  The  general  condition  had  also  greatly  im- 
proved ;  he  still  adhered  to  the  restricted  diet. 

1  Med.-Chir.  Trans.,  vol.  xxxvi. 
19 


290  DIABETES    MELLITUS, 

I  have  seen  Mr.  A.  from  time  to  time  up  to  the  present  date  (February, 
1865).  He  is  now  perfectly  restored  to  his  original  health  and  embon- 
point. The  restrictions  on  his  diet  have  long  since  been  relaxed.  He 
derived  considerable  advantage  from  the  use  of  almond  rusks  and  cakes, 
and  from  change  of  air  and  scene,  in  the  highlands  of  Scotland. 

November,  1871. — Mr.  A.  died  suddenly  two  years  ago  from  a  rup- 
tured aortic  aneurism. 

Case  7. — Mr.  M.,  a  retired  solicitor,  set.  72,  consulted  me  October 
17,  1863.  He  was  a  florid-complexioned,  stout,  healthy,  and  vigorous- 
looking  man  for  his  age.  Until  sixteen  months  ago  he  had  always 
enjoyed  excellent  health. 

Sixteen  months  ago  he  was  seized  with  a  low  febrile  complaint  of  un- 
determined character.  He  kept  his  bed  for  two  months,  and  was  greatly 
reduced  by  it ;  but  he  gradually  recovered,  and  went  to  Buxton  to  com- 
plete his  convalescence.  Before  going  to  Buxton  he  had  noticed  a  sweet 
taste  in  his  mouth  and  a  certain  sweetness  of  the  skin  of  his  hands  ;  and 
■when  there  he  noticed  a  great  thirst  and  frequent  calls  to  void  urine. 
With  the  continuance  of  these  symptoms  he  became  rapidly  thinner, 
and  sent  for  his  son-in-law,  Dr.  H.,  who  examined  the  urine,  and  dis- 
covered sugar.  Dr.  H.  found  the  symptons  of  diabetes  present  in 
moderate  intensity;  gums  spongy;  emaciation  very  considerable;  all 
his  embonpoint  gone ;  he  was  "  reduced  to  a  little  old  man."  The  urine 
amounted  to  six  and  ten  pints  a  day ;  and  his  thirst  was  so  tormenting, 
that  he  used  to  prepare  for  himself  a  large  jugful  of  oatmeal-water  and 
milk,  to  drink  at  night. 

At  this  period,  he  was  put  on  a  strict  flesh  diet,  with  green  vegetables. 
Great  benefit  followed  this  treatment ;  and  in  about  two  months  from 
the  first  onset  of  the  diabetic  symptoms,  he  had  recovered  from  the 
attack,  and  begun  to  recover  flesh  and  strength.  It  was  not  ascertained 
whether  the  sugar  disappeared  from  the  urine  when  the  other  symptoms 
subsided. 

He  continued  in  improved  health  for  five  or  six  months,  and  regained 
much  of  his  previous  vigor.  He  then  began  to  suffer  from  severe  lanci- 
nating pains  about  the  base  of  the  chest.  On  account  of  these  he 
sought  my  aid. 

He  complained  of  intense  pain,  of  neuralgic  character,  along  the  course 
of  the  lower  intercostal  nerves.  Up  to  the  day  before  his  visit  to  me, 
the  pain  had  been  limited  to  the  left  side,  but  it  had  now  invaded  the 
right  side ;  and  a  painful  circle  embraced  him,  in  a  line  corresponding 
to  the  attachments  of  the  diaphragm.  The  pain  was  darting,  burning, 
as  if  a  red-hot  iron  was  drawn  round  him ;  it  prevailed  in  paroxysms ; 
but  lately  the  remissions  had  never  been  complete ;  and  the  pain  came 
forward  to  the  mesial  line,  and  descended  into  the  testicles  and  penis. 
Nightly  opiates  were  required  to  induce  sleep.  He  was  very  nervous 
and  agitated,  especially  during  the  paroxysms,  but  there  was  no  fever. 
Tongue  clean,  pulse  quiet,  ranging  from  65  to  80  (he  often  counted  it 
himself) ;  heart's  sounds  were  healthy,  and  there  was  no  hypertrophy. 
The  pain  was  much  increased  by  motion  of  the  body,  as  in  walking. 
There  was  no  thirst ;  the  quantity  of  urine  was  not  increased.  Micturi- 
tion frequent  at  night;  appetite  pretty  fair. 


MILDER    TYPES.  291 

At  my  request  he  brought  me  the  urine  made  after  dinner  on  October 
18th;  its  specific  gravity  was  lO-'^O,  clear,  amber-colored;  it  contained 
no  trace  of  albumen,  but  as  much  as  5.1  per  cent,  of  sugar.  He  was 
ordered  5  grains  of  quinine,  with  some  carbonate  of  iron,  and  a  few  drop.s 
of  laudanum  at  night. 

October  19th. — He  brought  me  the  urine  made  before  breakfast;  its 
specific  gravity  was  1019,  and  it  contained  only  a  trace  of  sugar.  He 
had  passed  a  much  better  night  than  usual. 

20th. — Urine  before  breakfast  contained  a  trace  of  sugar ;  that  voided 
after  dinner  contained  a  good  deal  more. 

21st. — Urine  before  breakfast  was  quite  free  from  sugar;  that  after 
dinner  contained  4  per  cent.  He  still  complained  of  the  pain  round 
the  chest,  but  in  much  diminished  degree. 

25th. — Urine  before  breakfast  free  from  sugar ;  that  passed  after 
dinner  contained  only  0.8  per  cent. 

He  was  put  for  a  while  on  a  partially  restricted  diet.  The  urine  con- 
tinued for  some  days  to  show  traces  of  sugar  after  dinner.  After  this 
he  left  town  and  went  to  the  country,  continuing  to  improve.  This 
gentleman  is  now  (February,  1865)  in'very  fair  health  for  his  age ;  but 
I  cannot  state  whether  or  not  the  urine  contains  sugar. 

In  patients  of  this  class  I  have  generally  found  that,  although 
the  diahetic  symptoms  prove  mild  and  amenable  to  treatment, 
life  is  seldom  prolonged  beyond  a  few  years.  The  glycosuria 
may  disappear  or  become  insignificant;  but  the  constitution 
is  evidently  broken,  and  they  usually  die  in  two,  three,  or 
four  years,  either  from  cerebral  disease  or  from  pulmonary 
complications. 


CHAPTER    III. 


aHAVEL  AND  CALCULUS. 


Urolithiasis. 


GENEKAL  ETIOLOGY.  ' 

The  deaths  from  stone,  in  England  and  Wales,  in  the  five 
years  ending  1866,  amounted  to  an  annual  average  of  168.  It 
is  satisfactory  to  note  that  the  mortality  from  this  cause  exhibits 
a  progressive  diminution  in  the  last  thirty  years,  as  may  be  seen 
from  the  following  table  constructed  from  the  Registrar-General's 
Reports : 

Mortality  froTn  stone  in  England  and  Wales,  in  five  successive  quinquennial  periods.^ 
In  the  5  years  1838-42  the  yearly  average  of  deaths  from  stone  was     297 
"  1847-51  "  "  "  232 

"  1852-56  "  "  "  216 

"  1857-61  ''  "  "  184 

"  1862-66  "  "  "  168 

The  cause  of  this  diminution  is  to  be  chiefly  sought  for  in  the 
earlier  detection  of  the  stone,  and  earlier  resort  to  operation,  in 
recent  times ;  perhaps  also  in  the  improved  diet  and  water  sup- 
ply of  the  population.^ 

Calculous  disease  is  much  more  fatal  (as  might  have  been 
expected)  in  the  male,  than  in  the  female,  sex.  For  every  female 
that  died,  in  England  and  Wales,  in  the  ten  years,  1857-66, 
from  the  consequences  of  stone,  nearly  nine  males  perished. 

More  deaths  from  stone  occur  at  an  early  a^e,  and  in  the 
waning  years  of  life,  than  in  the  intermediate  periods,  as  is 
shown  by  the  following  table  : 

Table  showing  the  number  of  deaths  from  stone  at  different  ages  in  the  decade 
1857-66  in  England  and  Wales — Males  only  included. 

Under       5  years 116  deaths. 

Between    5  and  15  years 
15    "    25     " 


25 
85 
45 
55 
65 


35 
45 

55 
65 

75 


75  and  upwards 


114 
59 
62 
73 
132 
294 
517 
299 


^  The  returns  of  the  years  1843-46  are  tabulated  differently  from  the  remainder, 
and  cannot,  therefore,  be  included  in  this  table. 

2  The  suburban  district  of  Hulme  supplies  considerably  fewer"cases  of  stone  to 
the  Manchester  Infirmary  since  the  pipe-water  has  replaced  the  old  pump-water 
supply. 


GENERAL    ETIOLOGY.  293 

The  great  fatality  of  stone  above  tlie  age  of  fifty-live  is  due, 
not  so  much  to  the  greater  frequency  of  stone  at  that  epoch,  as 
to  its  more  severe  effects  on  the  constitution,  and  the  less  favor- 
able results  of  operation  in  advanced  life.  The  fregumcy  of 
stone  is  far  the  greatest  under  five  years  of  age;  and  next 
between  ten  and  fifteen  years.  It  then  diminishes  rapidly  until, 
the  thirty-fifth  year.  Above  this  age  cases  of  stone  become, 
again,  more  and  more  frequent,  until  the  age  of  sixty-five.  The 
following  table  indicates,  very  exactly,  the  prevalence  of  stone 
at  different  periods  of  life.  It  embraces  all  the  persons  who 
underwent  the  operation  of  lithotomy,  during  given  periods  of 
time,  at  the  following  hospitals:  Guy's,  St.  Thomas's,  Uni- 
versity College,  Norwich,  Cambridge,  Oxford,  Birmingham, 
Leicester,  and  Leeds. 

Table  showing  the  ages  of  1827  pe7-sons  who  under^weni  lithotomy  at  the  above 
hospitals— constructed  from  statistics  collected  in  Sir  H.  Thompson's  ivork  on 
Practical  Lithotomy  and  Lithotriiy. 

Under        5  years '*^^ 

Between    5  and  15  years -^28 

"         15    "    25  " '^57 

"         25    "    35  " 85 

"         35    "    45  " 90 

"         45    "    55  " ISS 

"         55    "    65  "       . •  ^25 

"         65    "    75  " 103 

75    "    81  "  ' 10 

E'o  countries  or  climates  are  altogether  free  from  calculous 
disorders;  but  some  localities  are  considerably  more  afflicted  by 
them  than  others.  Stone  and  gravel  are  common  in  England, 
France,  Teneriffe,  Iceland,  and  Egypt.^  They  are,  on  the  con- 
trarv,  rare  in  Sweden  and  Norway,  Styria,  and  some  other 
parts  of  the  Austrian  dominions.  In  Christiania,  3211  patients 
were  treated  in  the  general  hospital  during  a  period  of  four 
years,  and  among  them  there  was  only  one  stone  case.  In  the 
hospital  of  Gothenburg,  in  Sweden,  which  contains  sixty  beds, 
not  a  single  case  of  stone  was  received  in  fifteen  years. ^ 

The  climatic  conditions  favorable  to  the_  prevalence  of  stone 
appear  to  vary  within  narrow  topographical  limits.  Of  the 
eleven  registration  districts  into  which  England  and  Wales  are 
divided,  the  eastern  counties  of  Norfolk  and  Suffolk  furnVsh  the 
largest  proportion  of  deaths  from  stone.  Next  to  these  come 
the  North  Midland  counties.     The  fewest  deaths  from  stone  (as 

1  The  frequency  of  stone  in  Egypt  is  due  to  the  ravages  of  the  Bllharzia 
htematobia,  a  minute  parasite  which  infests  the  urinary  organs  in  hot  countries. 
{See  Bllharzia.) 

2  Civiale,  Traiti^  de  I'Affection  Calculeuse,  p.  580. 


294 


GRAVEL    AND    CALCULUS. 


compared  to  the  total  mortality)  are  furnished  b}^  Lancashire 
and  Cheshire,  and  by  the  Southwestern  counties.^ 


CLASSIFICATION  OF  UEINAEY  CALCULI,  THEIK  CHEMICAL 
CHAEACTBES,  OEIGIN",  GEOWTH,  AND  GENEEAL  CLINICAL 
HISTOEY. 

Urinary  calculi  may  be  classified,  according  to  their  chemical 
composition,  into  eight  primary  and  one  secondary  species.  The 
primary  species  are :  1.  Uric  acid.  2.  Urates.  3.  Oxalate  of 
lime.  4.  Cystine.  5.  Xanthine.  6.  Urostealith.  7.  Bone  earth 
(basic  phosphate  of  lime).  8.  Carbonate  of  lime.  The  sec- 
ondary concretion  is  composed  of  a  mixture  of  the  phosphate 
of  lime  and  the  ammoniaco-magnesian  phosphate. 

In  addition  to  these,  which  are  composed  of  normal  or  abnor- 
mal, but  strictly  urinary,  ingredients,  two  other  species  are 
occasionally  found  in  the  urinary  passages  which  have  an  origin 
extraneous  to  the  urine.  These  are  Jibrine  or  blood  concretions 
and  prostatic  calculi. 

Urinary  concretions  always  contain,  in  addition  to  their  proper 
components,  slight  admixtures  of  animal  matters,  viz.,  mucus, 
epithelium,  pigment,  and,  generally  also,  more  or  less  desiccated 
blood  and  pus. 

The  term  "gravel"  is  given  to  concretions  of  small  dimen- 
sions, which  are  not  too  large  to  be  spontaneously  voided  by  the 
urethra;  the  larger  masses  are  called  "  stones,"  or  "  calculi." 

Calculous  formations  are  said  to  be  primary^  when  they  are 
deposited  from  the  unchanged  urine,  owing  to  some  inherent 
vice  in  its  composition ;  and  secondary,  when  the  deposit  is  due 
to  ammoniacal  decomposition  of  the  urine  in  the  lower  urinary 
passages. 

It  is  essential  to  recognize  this  difference  in  order  to  under- 
stand the  mode  of  growth  of  urinary  calculi,  and  the  principles 
which  should  guide  their  medical  treatment. 

1  The  following  table  shows  the  proportion  of  deaths  from  stone  in  each  of  the 
eleven  registration  districts  of  England  and  Wales,  for  every  100,000  deaths  from 
all  causes,  in  the  ten  years  1857-66.  Males  only  are  included.  (Constructed  from 
the  Eegistrar-General's  Eeports.) 


North- Western 

South -Western 

Northern    . 

West- Midland 

South-Midland 

Yorkshire  . 

London 

Monmouthshire 

South-Eastern 

North-Midland 

Eastern 


and  Wales 


34 
46 
54 
64 
71 
75 
90 
91 
93 
98 
115 


CLASSIFICATION    OF    URINARY    CALCULI.  295 

It  has  been  already  cxi)laincd  that  vvlieiiovor  the  urine  l)ecorrieH 
decomposed  and  anunoniacal,  itn  earthy  constituents  are  pre- 
cipitated as  a  sediment  composed  of  pho8[)liate  of  hme  and  the 
ammoniaco-magnesiau  phosphate,  often  mixed  with  small  quan- 
tities of  urate  of  ammonia  and  carbonate  of  lime.  This  is 
identical  with  the  secondary  phosphatic  deposit  on  urinary  cal- 
culi/ Its  production  is  due  to  tlie  transformation  of  urea  into 
carbonate  of  ammonia.  Any  obstacle  which  delays  the  urine 
in  its  channels,  and  prevents  its  speedy  and  complete  evacuation, 
tends  to  bring  about  this  change.  The  presence  of  a  calculus 
in  the  bladder  presents  a  condition  highly  favorable  to  the  pro- 
duction of  aramoniacal  urine,  and  to  the  Y^'ecipitation  of  the 
secondary  phosphatic  deposit.  Accordingly,  it  is  found  that 
calculi  which  have  been  long  detained  in  the  bladder,  are  fre- 
quently covered  over  with  a  phosphatic  incrustation.  Indeed, 
it  may  be  said  that  this  is  the  proper  ultimate  stage  and  last 
chapter  in  the  history  of  every  urinary  concretion,  unless  its 
career  be  cut  short  by  spontaneous  expulsion,  or  removal  by 
surgical  operation. 

The  epoch  at  which  the  secondary  deposit  begins  to  form  is 
quite  uncertain,  and  depends  on  the  concurrence  of  cystitis. 
Sometimes  small  calculi,  weighing  only  a  few  drachms,  are 
found  covered  with  a  thick  investment  of  phosphates ;  in  other 
instances  large  calculi,  weighing  many  ounces,  are  found  with- 
out any  traces  of  phosphatic  incrustation.  So  long  as  the  urine 
remains  acid  the  surface  of  the  stone  remains  free  from  phos- 
phates, but  as  soon  as  the  urine  becomes  freely  ammoniacal,  the 
secondary  deposit  begins  to  accumulate. 

It  follows  from  these  facts,  that  a  solvent  treatment  which 
may  have  been  applicable  in  the  early  existence  of  a  stone, 
ceases  to  be  so  when  the  urine  becomes  ammoniacal  and  a 
secondary  deposit  has  taken  place  on  its  surface. 

The  principal  points  relating  generally  to  the  structure  and 
growth  of  urinary  calculi  are  embraced,  in  the  following  propo- 
sitions : 

1.  Calculi  may  consist  entirely  of  one  ingredient,  as  uric  acid, 
oxalate  of  lime,  cystine,  etc. ;  or  two  or  more  primary  deposits 
may  alternate  with  each  other  in  the  form  of  layers,  so  as  to 
constitute  an  alternatinci  calculus. 

2.  The  most  common  alternations  are  uric  acid  and  oxalate 
of  lime ;  but  any  primary  deposit  may  alternate  with  any  other 
primary  deposit :  as  cystine  with  uric  acid ;  uric  acid  with  bone 
earth ;  or  oxalate  of  lime  and  bone  earth.  The  last  two  cases, 
however,  are  excessively  rare.    The  number  of  layers  composing 

1  The  fetid  incrustation  which  covers  public  urinals  is  likewise  of  similar 
nature. 


296  GRAVEL    AND    CALCULUS. 

an  alternating  calculus  is  quite  uncertain ;  there  ma}^  be  only 
three  or  four,  or  twenty  or  thirty.  The  thickness  of  the  layers 
varies  conversely  with  their  number, 

3.  A  calculus  consisting  of  only  one  substance  has  usually  a 
stratified  arrangement,  and  exhibits  an  indefinite  number  of 
concentric  layers.  Such  is  usually  the  structure  of  uric  acid, 
oxalate  of  lime,  and  phosphatic  calculi.  But  sometimes  the  cal- 
culous matter  is  deposited  in  vertical  lines  radiating  from  the 
centre.  This  is  the  usual  structure  of  cystine  calculi.  Some- 
times one  portion  of  a  stone  has  a  radiated,  and  another  portion 
a  stratified  formation. 

4.  Most  urinary  calculi  are  divisible  into  a  central  portion  or 
nucleus,  and  an  outer  portion  or  body.  There  is  also  not  unfre- 
quently  an  outer  investment,  or  crust,  of  phosphatic  deposit. 

5.  The  nucleus  may  be  of  the  same  nature  as  the  body,  or 
dififer  from  it.  The  nucleus  may  consist  of  uric  acid,  urates, 
oxalate  of  lime,  or  any  other  primary  formation,  or  it  may  be  a 
clot  of  blood  or  a  mass  of  mucus ;  or,  lastly,  it  may  consist  of 
some  foreign  body  introduced  from  without. 

6.  The  determining  causes  of  the  formation  of  urinary  calculi 
are  still  but  imperfectly  known.  The  more  usual  are  the  follow- 
ing :  (a)  An  excessive  proportion  of  the  precipitated  ingredient 
in  the  urine ;  {b)  A  too  acid  state  of  the  urine,  which  diminishes 
its  solvent  power  over  uric  acid  and  the  urates ;  (c)  An  alkaline 
state  of  the  urine.  If  the  alkalescence  be  due  to  fixed  alkali, 
the  bone-earth  phosphate  and  carbonate  of  lime  are  liable  to 
precipitation ;  this  is,  however,  a  very  rare  contingency  in  the 
human  subject,  though  common  in  the  herbivora.  If  the  alka- 
lescence be  due  to  carbonate  of  ammonia,  the  secondary  phos- 
phates are  precipitated;  {d)  Deficiency  of  chloride  of  sodium 
and  the  alkaline  phosphates  in  the  urine,  reduces  its  solvent 
power  on  uric  acid  (Heller);  (e)  The  presence  in  the  urine  of  an 
abnormal  constituent  of  sparing  solubility,  such  as  cystine  or 
xanthine;  (/)  The  accidental  presence  of  a  body  suitable  to  form 
a  nucleus,  such  as  a  small  mass  of  concrete  blood,  mucus,  epi- 
thelium, or  an  extraneous  body,  such  as  a  bit  of  bougie,  a  piece 
of  bone,  or  of  a  wire  or  needle,  a  bit  of  sealing-wax,  and  so 
forth. 

Considerable  light  has  been  thrown  on  the  mode  of  origin  of 
urinary  calculi  by  an  examination  of  the  microscopical  structure 
of  their  nuclei.  Dr.  V.  Carter  found  that  the  actual  nucleus 
consisted  nearly  always  of  globular  forms  of  urates  and  oxalate 
of  lime  (dumb-bells  and  spheroids),  and  not  ordinary  crystals 
of  these  substances.  The  researches  of  liainey  and  Ord  have 
shown  that  these  globular  forms  are  only  produced  when  pre- 
cipitation takes  place  slowly  in  a  colloid  medium;  and  Carter 
found  that  a  colloid  matrix  always  exists  in  the  nuclear  forma- 


VARIETIES    OF    URINARY    GRAVEL    AND    (JAI.fJi;iJ 


297 


tions  of  urinary  calculi.  It  would  therefore  appear  probable 
that  the  initial  Btep  in  the  formation  of  a  calculus  is  the  exudation 
of  some  colloid — mucus,  or  some  other  al})nminoid  substance 
— into  the  urinary  passages.  Into  this  colloid,  urates  or  oxalate 
of  lime,  or  both,  arc  precipitated,  and  combining  with  it,  form 
molecular  aggregations  of  a  globular  character,  which  constitute 
the  foundation  of  the  subsequent  growth.  Under  what  con- 
ditions the  colloid  is  exuded  cannot  be  with  certainty  explained  ; 
but  the  probability  is  that  congestive  or  subinflanmiatory  states 
of  the  kidneys,  such  as  occur  in  the  febrile  state,  give  occasion 
to  such  an  exudation  and  supply  a  starting-point  to  a  process 
which  does  not  attract  attention  until  after  a  long  lapse  of  time.' 

OF  THE  PARTICULAK  VAKIETIES  OF  URIJTAEY  GEAVEL 
AND  CALCULI. 

1.  Uric  Acid, — This  is  by  far  the  most  frequent  species  of 
urinary  concretion.  It  constitutes  probably  five-sixths  of  all 
renal  concretions,  and  of  vesical  calculi  which  have  only  re- 
cently descended  from  the  kidney.  As  gravel,  uric  acid  may 
be  passed  in  the  form  of  small  distorted  crj^stalline  agglomera- 

FiG.  40. 


Section  of  a  uric  acid  calculus. 


tions,  or  as  little  smooth  spherical  bodies,  ranging  from  the  size 
of  a  poppy  seed  to  that  of  a  mustard  seed,  or  in  flattened  warty 
concretions  as  large  as  split  peas.  All  these  have  a  yellowish, 
brownish,  or  reddish  color.  They  are  derived  from  the  kid- 
ney, and  may  be  discharged  singly  or  in  numbers  at  irregular 
intervals. 


^  See  Carter  "  On  the  Microscopic  Structure  and  Formation  of  Urinary  Cal- 
culi." Lond.,  1873.  Also  Dr.  Ord's  paper,  Med.-Chir.  Trans.,  1875;  and  his 
work  "On  the  Influence  of  Colloids  upon  Crystalline  Form  and  Cohesion.'.' 
Lond.,  1879. 


298  GRAVEL    AND    CALCULUS. 

When  retained  in  the  bladder,  they  grow  into  flattened  oval 
calculi,  sometimes  roundish,  sometimes  elongated  like  an  almond. 
Theyvary  in  color  from  a  light  fawn  to  a  deep  brick-red,  accord- 
ing to  the"  quantity  and  nature  of  the  urinary  pigment  which 
they  contain.  Their  surface  is  usually  studded  with  minute 
tubercles,  or  mamillations,  which  are  worn  into  smooth  facets  if 
more  than  one  stone  coexist  in  the  bladder.  Their  weight  varies 
from  a  drachm  to  an  ounce,  but  sometimes  reaches  four  or  five 
ounces. 

Uric  acid  calculi  possess  considerable  hardness;  their  specific 
gravity  is  about  1.5.  Uric  acid  is  best  recognized  by  the  murexid 
test,  previously  described.  Its  most  important  properties,  from  a 
therapeutical  point  of  view,  are  its  solubility  in  weak  solutions 
of  the  carbonates  of  lithia,  potash,  and  soda,  and  its  insolubility 
in  strong  solutions  of  the  bicarbonates  of  potash  and  soda,  as 
well  as  in  water  and  dilute  acids. 

Pathologically,  uric  acid  is  closely  related  to  gout.  Hence, 
the  frequency  of  uric  acid  gravel  and  stone  in  the  wealthier 
classes  in  the  middle  and  later  periods  of  life. 

The  urine,  in  the  subjects  of  uric  acid  calculi,  is  acid,  and 
often  high-colored,  prone  to  deposits  of  uric  acid  crystals  and 
amorphous  urates, 

The  medical  treatment  of  this  class  of  calculi  will  be  described 
at  length  in  a  separate  section.     [See  Solvent  Treatment.) 

2.  Urate  Concretions. — The  same  confusion  has  existed  re- 
specting the  composition  of  these  concretions,  as  respecting  that 
of  the  amorphous  urate  deposit.  They  are  usually  designated 
urate  of  ammonia,  but  their  chemical  nature  requires  reexami- 
nation. 

They  constitute  small,  soft  agglomerations  in  the  kidneys — 
rarely  in  the  bladder;  and  are  almost  confined  to  young  chil- 
dren. Heller^  states  that  he  has  found  them  several  times  in 
the  kidneys  and  ureters  of  sucking  infants  in  the  Vienna  Found- 
ling Hospital.  They  formed  small  irregular  clumps,  sometimes 
heaped  together  into  a  mass  as  large  as  a  kidney  bean.  Heller 
encountered  similar  calculi  on  two  occasions  in  adults.  Calculi 
wholly  composed  of  urates  are  very  rare,  and  never  reach  a 
large  size ;  but  globular  masses  of  urates  nearly  always  exist  in 
the  centre  of  a  urinary  calculus,  although  its  bulk  may  be  formed 
of  some  other  ingredient. 

The  deposition  of  clumps  of  urate  of  soda  in  the  urinary  pas- 
sages is  not  uncommon  in  the  febrile  complaints  of  infants  and 
young  children ;  and  it  seems  not  unlikely  that  some  of  these 
clumps  may  be  retained  in  the  pelvis  of  the  kidney  or  in  the 
bladder,  and  become  the  nuclei  of  future  calculi ;  and  that  the 

■  Harnconcretionen,  p.  134. 


VARIETIES    OF     UKJNAKY    GRAVEL    AND    CALCULI.       2U\) 

excessive  frequency  of  calculi   in  children  is  due  to  this  cause 
{see  p.  98). 

The  urine  from  which  this  variety  of  concretion  is  deposited, 
has  an  acid  reaction,  and  the  medical  treatment  is  identical  with 
that  of  uric  acid  calculi.  The  circumstances  under  which  this 
concretion  is  deposited,  must  be  carefully  distinguished  from 
those  in  which  urate  of  ammonia  (of  undoubted  composition)  is 
deposited  in  an  ammoniacal  urine  mixed  with  secondary  phos- 
phates. 

Urate  concretions  are  distinguished  chemically  by  their  solu- 
bility in  hot  water. 

3.  Oxalate  of  Lime  or  Mulberry  Calculus.  —  Oxalate  of 
lime  may  be  discharged  as  minute  concretions,  or  gravel,  from 
the  kidney,  or  grow  to  be  a  stone  in  the  bladder.  In  the  former 
case  the  concretions  are  usually  smooth,  rounded,  grayish-dark 
bodies,  resembling  hemp-seed. 

Vesical  calculi  of  this  class  are  exceedingly  hard,  and  break 
into  sharp  angular  fragments  when  crushed  by  the  lithotrite 
They  are  usually  of  a  spherical  shape ;  their  surface  is  tubercu- 
lated  like  a  mulberry  (Fig.  41),  and  is  usually  of  a  blackish- 

FiG.  41. 


Oxalate  of  lime  ur  mulberry  calcnhis. 

brown  color.  Sometimes,  however,  they  are  oval  and  smooth, 
and  of  a  bluish-gray  color. 

The  nucleus  of  a  mulberry  calculus  is  frequentl}^  composed  of 
uric  acid;  and,  conversel}^  (though  much  more  rarely),  a  uric 
acid  stone  may  have  a  nucleus  of  oxalate  of  lime.  Beale  and 
Carter  have  further  shown,  that  in  the  centre  of  a  uric  acid 
nucleus,  there  is  often  a  microscopic  clump  of  dumb-bells  of 
oxalate  of  lime. 

Calculi  composed  of  alternate  layers  of  oxalate  of  lime  and 
uric  acid  are  more  common  than  those  composed  of  oxalate  of 
lime  alone.  These  laj^ers  may  form  complete  concentric  cap- 
sules, or  be  partial  and  imperfect.  In  the  latter  case  the  con- 
cretion is  amenable  to  the  solvent  and  disintegrating  action  of 
the  alkaline  carbonates;  in  the  former  it  is  wholly  beyond  the. 
power  of  such  solvents. 


300  GRAVEL    AND    CALCULUS. 

Oxalate  of  lime  is  insoluble  in  alkaline  carbonates  and  organic 
acids;  but  it  dissolves  in  nitric  and  muriatic  acids.  When 
heated  before  the  blowpipe,  it  first  blackens,  and  finally  leaves 
a  bulky  white  ash  of  caustic  lime,  which  blues  moistened  litmus 
paper. 

During  the  formation  of  oxalate  of  lime  calculi,  the  urine  is 
always  acid. 

4.  Cystine. — Gravel  and  calculi  of  cystine  belong  to  the  rarer 
species,  of  urinary  concretions.  They  are  usually  found  in  the 
bladder  as  large  calculi,  but  sometimes  they  are  discharged 
spontaneously  as  gravel.  I  have  in  my  collection  two  examples 
of  pure  cystine  calculi  passed  spontaneously  {see  Fig.  42).     One 


Cystine  calculi  spontaneously  voided. 

of  them  is  a  small  lenticular  mass  weighing  a  grain  and  a  half. 
The  other  is  cylindrical  in  shape,  an  inch  and  a  quarter  in 
length,  and  weighing  twenty-seven  grains.  Both  have  a  crys- 
talline granular  surface  and  a  light  yellow  color.  Sometimes 
vesical  calculi  of  cystine  attain  a  weight  of  three  or  four  ounces. 
They  are  usually  egg-shaped,  of  a  full  honey-yellow  color,  mamil- 
lated  on  the  surface,  and  lustrous,  as  if  studded  with  minute 
crystals.  When  cut  into,  they  show  a  radiated  structure,  and 
an  obscurely  transparent  brilliance  like  yellow  beeswax.  They 
are  usually  composed  of  pure  cystine,  unmixed  with  any  other 
substance.  Sometimes  the}^  have  a  nucleus  of  uric  acid.  In  a 
specimen  in  the  Museum  of  Owens  College  (Fig.  43)  the  cen- 

FiG.  43. 


Section  of  a  cystine  calculus,  with  a  nucleus  of  uric  acid,  and  an  external  coat  of  phosjjhate. 

tral  nodule  is  uric  acid ;  around  this  is  a  body  of  pure  cj^stine ; 
overlying  this  a  layer  of  mixed  uric  acid  and  cystine  ;  and 
enveloping  the  whole  a  crust  of  secondary  phosphates,  mixed 
with  cystine. 

Cystine  calculi  possess  the  curious  property  of  assuming  a 
pale  green  color  when   long    exposed   to   full    daylight.      The 


VARIETIES    OF    URINARY    GRAVEL    AND    CALCULI.      301 

specimen  just  referred  to  iiftbrded  an  interesting  example  of 
this  change.  The  calculus  liad  been  divided  equatorially ;  one- 
half  lay  in  the  cabinet  with  its  cut  surface  downwards,  and  the 
other  half  with  the  cut  surface  upwards,  exposed  to  the  light. 
The  latter  had  a  delicate  emerald-green  tint,  while  the  former 
preserved  its  original  yellow  color. 

Another  curious  circumstance  in  the  history  of  cystine,  is 
its  tendency  to  run  in  families.  Dr.  Marcet  gives  an  account 
of  two  brothers  in  whose  kidneys  cystine  calculi  were  found. 
Both  Lenoir  and  Civiale  extracted  cystine  calculi  from  the 
bladders  of  two  brothers.  Toel  relates  the  history  of  two 
sisters  and  a  mother  who  voided  cystine  with  the  urine. 
Ebstein^  also  has  described  cystinuria  as  occurring  in  two 
brothers. 

Cystine  calculi  are  much  more  friable  than  uric  acid  or 
oxalate  of  lime.  They  are  easily  scraped  with  the  nail,  and 
otfer  especially  favorable  objects  for  treatment  by  lithotrity. 
My  late  colleague,  Mr.  Southam,  showed  me  a  quantity  weigh- 
ing ninety  grains  of  the  fragments  of  a  pure  cystine  calculus, 
which  had  been  voided  by  a  little  girl  four  years  of  age  after  a 
single  crushing. 

Cystine  is  recognized  with  great  facility.  If  a  particle  be 
placed  on  a  watch-glass,  or  on  a  slip  of  glass,  and  treated  with 
caustic  ammonia,  it  speedily  dissolves ;  by  exposure  to  the  air 
for  a  few  hours,  the  volatile  alkali  exhales,  and  beautiful  six- 
sided  crystals  are  deposited,  which  are  highly  characteristic 
{see  Figs.  14  and  15).  Cystine  is  also  soluble  in  the  mineral 
acids ;  and  in  the  tixed  alkalies  and  their  carbonates ;  but  it  is 
precipitated  by  organic  acids  and  by  carbonate  of  ammonia. 

5.  Xanthine  calculi  are  excessively  rare.  [See  Xanthine, 
p.  111.) 

6.  Fatty  or  Saponaceous  Concretions.  Urostealith  (of 
Heller). — In  the  Museum  of  the  College  of  Surgeons  of  Lon- 
don there  are  two  magnificent  specimens  of  vesical  calculi, 
composed  of  a  central  fatty  or  saponaceous  mass  surrounded 
with  a  thick  investment  of  phosphates  (Fig.  44).  Both  belonged 
to  Hunter's  collection,  and  both  are  figured  and  described  in 
the  catalogue  of  calculi  published  in  1842.  They  are  described 
as  "  consisting  of  the  earthy  phosphates  deposited  upon  a  mass 
of  oleate  and  margarate  of  lime,"'  This  mass  is  of  a  light'yel- 
low  color,  and  its  irregularities  correspond  with  those  of  the 
cavity  in  w^iich  it  loosely  lies.  At  p.  129  of  the  catalogue,  the 
following  ingenious  remarks  are  made  respecting  the  probable 
origin  of  these  stones :  "  On  account  of  some  real  or  supposed 
disease  of  the  bladder,  a  solution  of  soap  has  been  injected  into 

1  Deutsch.  Arch.,  Bd.  xxiii. 


302  GRAVEL    AND    CALCULUS. 

its  cavity ;  mutual  decomposition  between  the  soap  and  the  salts 
of  the  urine  has  been  the  necessary  result;  the  alkali  of  the 
former  uniting  with,  and  forming  soluble  compounds  with,  the 
phosphoric  and  other  acids  of  the  urine,  while  the  earthy  bases 
of  the  urine  have  precipitated,  in  combination  with  the  fatty 
acids  of  the  soap,  in  the  form  of  a  semi-gelatinous   sparingly 

Fig.  44. 


I- 


Section  of  a  fatty  or  saponaceous  concretion  (firosteiiliik)  surrounded  with  pliospliates.     From  the 
Museum  of  the  London  College  of  Surgeons. 

soluble  compound,  being  in  fact  an  earthy  soap;  this  substance, 
acting  as  a  foreign  body  in  the  bladder,  has  induced  the  deposi- 
tion of  the  phosphates,  and  given  rise  to  the  formation  of  a 
calculus." 

The  fatty  or  saponaceous  masses  here  described  are  probably 
of  the  same  nature  as  those  described  by  Heller  in  1845,  and 
named  by  him  Vrostealith}  Only  one  other  case  has  been  pub- 
lished ;  it  was  observed  by  Dr.  W.  Moore  in  1853.' 

Heller's  patient  was  a  man,  24  years  of  age,  who  passed  a 
number  of  small  concretions  about  as  large  as  peas.  When 
fresh,  they  were  soft  and  elastic,  like  India-rubber,  but  dried 
into  hard,  brittle,  wax-like  masses.  They  dissolved  readily  in 
caustic  potash,  forming  a  soap.  They  also  dissolved  readily  in 
ether,  but  with  difficulty  in  alcohol.  In  hot  water  they  did  not 
dissolve,  but  softened.  They  melted  with  heat,  and  eventually 
burned  with  a  bright  yellow  flame,  exhaling  an  odor  of  shellac 
and  benzoin.  They  contained  a  large  quantity  of  earthy  phos- 
phates. 

Dr.  Moore's  specimens  consisted  of  two  very  small  dark  brown 

1  Harnconcretionen,  p.  146  ;   alpo  Heller's  Archiv,  Bd.  ii.  p.  L 
^  Dublin  Quarterly  Journ.  of  Med.  Science,  vol.  xvii.  p.  473. 


VARIETIES    OF    URINARY    GRAVEL    AND    CALCULI.       308 

calculi,  which  had  a  soft  wax-like  cotisistencc,  and  a[)pcarod 
to  consist  of  a  lime  soap.  They  partly  dissolved  in  hot  alco- 
hol;  and  the  solution,  when  cold,  deposited  a  whitish  matter, 
which  exhibited  numerous  fat  globules,  but  no  crystalline  plates, 
Wheu  incinerated  before  the  blowpipe  they  yielded  a  white, 
alkaline,  calcareous  ash.  A  year  later.  Dr.  Moore  received 
from  Dr.  R.  Adams  two  calculi  taken  from  the  body  of  this 
patient.  One  was  a  large  phosphatic  stone,  in  the  centre  of 
which  was  a  cavity  containing  some  of  the  same  dark  brown 
substance.  Dr.  W.  Davy,  who  examined  a  portion  of  this, 
judged  it  to  be  composed  of  lime  "in  combination  with  the  fat 
or  waxy  substance  forming  some  organic  combinations  with  the 
fatty  acids." 

7.  Carbonate  of  Lime. —  Concretions  of  carbonate  of  lime 
are  very  rare  in  the  human  subject;  Those  which  have  hitherto 
been  encountered  were  of  small  dimensions,  varying  from  the 
size  of  the  smallest  visible  granules  to  that  of  a  hazelnut,  smooth 
on  the  surface,  gray,  yellowish,  or  bronze  colored — sometimes 
with  a  metallic  lustre,  and  generally  very  hard. 

The  following  remarkable  case,  in  which  myriads  of  minute 
calculi  of  carbonate  of  lime  were  voided  with  the  urine,  was 
described  in  the  first  edition  of  this  work  as  an  example  of  the 
spontaneous  expulsion  of  prostatic  calculi,  but  a  communication 
I  have  since  received  from  Dv.  Haldane,  of  Edinburgh,  has  con- 
vinced me  that  they  were  derived  from  the  kidneys,  and  not 
from  the  prostate. 

The  patient  was  a  gentleman  seventy  years  of  age,  suffering 
from  enlarged  prostate,  under  the  care  of  Mr.  George  Hun- 
stone,  of  this  city.  On  the  20th  of  April,  1864,  Mr.  Hunstone 
brought  me  a  specimen  of  the  urine  for  examination.  It  was 
ammoniacal,  and  contained  a  good  deal  of  pus.  At  the  bottom 
of  the  phial  were  a  large  number  of  minute  amber-colored  cal- 
culi— the  largest  of  which  were  about  the  size  of  poppy  seeds, 
and  the  smallest  only  just  visible  to  the  naked  eye,  as  bright 
specks.  On  subsequent  occasions  Mr.  Hunstone  brought  me 
-additional  quantities  of  urine  containing  similar  bodies.  Alto- 
gether I  obtained  about  eight  grains  of  these  calculi ;  they  were 
easily  separated  from  the  urine  by  levigation  and  decantation. 
Mr.  Hunstone  stated  that  the  patient  had  been  in  the  habit  of 
voiding  these  calculi  for  some  months,  at  frequent  intervals. 
The  patient  died  some  few  months  afterwards,  and,  unfortu- 
nately, no  opportunity  was  afforded  of  making  a  post-mortem 
examination. 

The  largest  of  the  specimens  in  my  possession  is  about  the 
size  of  a  mustard-seed ;  there  are  a  good  many  as  large  as 
poppy  seeds  ;  but  several  hundreds  are  less  than  a  quarter  of 
this  size,  and  many  thousands  are  still  smaller.    They  are  mostly 


304 


GRAVEL    AND    CALCULUS. 


spherical  in  shape ;  many  are  rudely  cubical  or  pyramidal.  They 
possess  a  full  amber  color,  and  are  linely  translucent.  Under 
the  microscope  they  present  the  appearance  represented  in 
Fig.  45,  and  exhibit  an  infinite  series  of  concentric  lines.  The 
centre  or  nucleus  is  variously  composed.  In  some  of  them  it  is 
an  object  resembling  a  glandular  cell,  in  others  a  prismatic 
crystal,  in  others  amorphous  earthy-looking  matter.  In  some, 
again,  the  nucleus  is  double ;  in  others,  treble,  or  even  quadruple 
(Fig.  45).     With  polarized  light  they  display  a  dark  cross,  as 


Fig.  45. 


Carbonate  of  lime  calculi  spontaneously  voided  with  the  urine — highly  magnified. 

represented  in  the  lower  right-hand  corner  of  the  figure.    When 
crushed  they  break  into  angular  fragments. 

The  calculi  dissolve  rapidly  in  mineral  acids,  with  abundant 
disengagement  of  carbonic  acid — leaving  ragged,  brown,  flaky, 
organic  remnants.  Acetic  acid  acts  very  slowly  upon  them, 
without  visible  disengagement  of  carbonic  acid;  but  in  the 
course  of  two  or  three  days  all  the  mineral  matter  is  taken  up, 
and  the  animal  matrix  is  left,  as  soft,  light  balls,  preserving  the 
stratified  appearance  of  the  original  calculi,  but  with  a  diminu- 
tion of  their  original  translucency.  They  are  unaffected  by 
caustic  potash.  The  murexid  test  yields  not  the  slightest  evi- 
dence of  uric  acid.     When  heated  to  whiteness  before  the  blow- 


VARIETIES    OF    URINARY    GRA.VKJ.    ANJ>    CALCULI.      305 

pipe,  their  surfaces  fuse  into  a  brilliant  iron-gray  enamel,  which 
protects  the  deeper  parts.  As  the  incandescent  calculi  cool, 
the  enamelled  surfaces  crack  into  numerous  minute  polygonal 
spaces.  The  solution  of  the  calculi  in  muriatic  acid  throws 
down  an  abundant,  white,  flocculent  precipitate  when  saturated 
with  caustic  ammonia.  These  reactions  indicate  that  they  are 
composed  of  an  animal  matrix  impregnated  with  carbonate  of 
lime  mixed  with  a  little  phosphate  of  lime. 

Dr.  Haldane's  communication  above  referred  to  contains  an 
account  of  a  case  in  which  calculi,  identical  in  every  respect 
with  those  just  described,  were  found  in  the  kidney  after  death. 
Dr.  Haldane's  notes  are  as  follows : 

"W.  A.,  a  mason,  aged  33,  was  admitted  into  the  Edinburgh  Infirmary 
under  Dr.  Gillespie,  on  the  IGth  of  October,  1856.  Fifteen  months  before 
admission  he  strained  his  hack  while  engaged  in  raising  a  large  stone. 

"  Two  months  afterwards  an  abscess  formed  over  the  upper  part  of 
the  sacrum,  which  was  poulticed,  opened,  and  matter  was  discharged. 

"  The  abscess  healed  up,  but  matter  again  formed  ;  the  second  abscess 
burst  about  two  months  before  his  admission  into  hospital.  During  the 
greater  part  of  the  fifteen  months  he  had  been  at  his  work. 

"When  admitted  into  the  hospital  he  complained  of  pain  in  the  back 
and  general  weakness.  There  was  an  opening  at  the  right  side  of  the 
sacrum,  from  which  pus  discharged.  A  probe  could  be  introduced  its 
whole  length,  and  seemed  to  pass  towards  the  anterior  part  of  the  lumbar 
vertebrae.     He  sank  gradually,  and  died  on  the  21st  of  April,  1857. 

"No  urinary  symptoms  were  noticed  during  his  residence  in  the 
hospital. 

"  I  examined  the  body  on  the  22d  of  April.  A  large  accumulation 
of  matter  was  found  in  front  of  the  bodies  of  the  lumbar  vertebrae ; 
there  was  caries  of  the  anterior  part  of  the  bodies  of  the  first  four.  The 
spinal  cord  was  not  affected. 

"  The  heart  and  lungs  were  natural. 

"The  liver  was  small,  weighing  31  ounces,  but  was  healthy  in 
structure. 

"  The  right  kidney  weighed  5  ounces ;  it  was  anaemic  but  healthy, 
except  that  a  few  gritty  particles  were  embedded  in  some  of  the  cones. 
These  were  found  to  consist  partly  of  carbonate  of  lime. 

"The  left  kidney  weighed  4 J  ounces.  In  the  pelvis  was  about  half  a 
teaspoonful  of  sandy-looking  material,  held  together  by  a  flocculent 
substance,  which  resembled  coagulated  blood.  The  sandy  matter  was 
in  small  particles,  generally  about  the  size  of  grains  of  sand  ;  some  were 
as  large  as  hemp-seeds.  The  lining  membrane  of  the  pelvis  was  thick- 
ened, and  at  some  points  appeared  slightly  abraded.  The  kidney  was 
a  little  atrophied,  owing  to  dilatation  of  the  pelvis.  The  ureters  were 
natural.  The  bladder  was  contracted  ;  it  contained  about  a  teaspoonful 
of  urine,  which  unfortunately  was  not  examined. 

"  I  looked  upon  this  case  as  possibly  an  example  of  the  calcareous 
metastasis  described  by  Virchow.  When  in  connection  with  absorption 
of  bone,  carbonate  and  phosphate  of  lime  are  deposited  elsewhere." 

20 


306  GRAVEL    AND    CALCULUS. 

Dr.  Haldane  was  good  enough  to  send  me  a  sample  of  the 
calculi  obtained  from  the  kidney  in  this  case ;  and  I  had  no  dif- 
ficulty in  deciding  on  their  absolute  identity  both  in  naked-eye 
and  microscopic  appearance,  as  well  as  in  chemical  composition, 
with  those  examined  by  myself.  It  seems  also  highly  probable 
that  the  history  of  their  occurrence  was  strictly  analogous. 

In  the  nineteenth  volume  of  the  "  Transactions  of  the  Patho- 
logical Society,"  Mr.  Wagstaffe  describes  a  "  large  branching 
calculus,"  composed  of  carbonate  of  lime,  removed  after  death 
from  the  right  kidney  of  a  man  aged  forty-two.  Several  small 
ones,  of  similar  composition,  were  also  found  in  the  same  kid- 
ney. Dr.  Ord  also  has  described  calculi  composed  of  carbonate 
of  lime.^ 

8.  Basic  Phosphate  of  Lime  or  Bone-earth. — Concretions 
of  this  substance  alone  are  very  rare.  They  were  formerly 
confounded  with  the  mixed  phosphates  which  constitute  the 
secondary  deposit.  They  vary  in  size  from  a  pea  to  a  hen's 
egg.  They  are  white  and  chalky  in  appearance,  and  of  a  soft, 
smoothish  exterior,  with  an  earthy  fracture.  Sometimes  their 
texture  is  loose,  sometimes  very  compact. 

Bone-earth  rarely  alternates  with  any  other  deposit;  occa- 
sionally, however,  it  does  so.  There  is  a  fine  specimen  in 
the  museum  of  the  Manchester  Infirmary,  in  which  bone-earth 
alternates  with  uric  acid. 

When  the  urine  is  rendered  alkaline  by  alkalizing  salts,  or 
becomes  alkaline  after  a  meal,  the  bone-earth  phosphate  is 
sometimes  abundantly  deposited ;  but,  from  its  uncrystalline 
condition,  it  has  very  little  te^idency  to  agglomerate  into  con- 
cretions. Patients  may  pass  an  alkaline  and  turbid  urine  (from 
this  cause)  for  months,  without  practically  any  risk  of  the 
formation  of  a  stone. 

9.  Mixed  or  Secondary  Phosphates  (Fusible  Calculus). — 
The  composition  and  production  of  this  deposit  from  ammo- 
niacal  urine  has  been  already  explained.  It  rarely  forms  the 
centre  of  a  urinary  calculus ;  but  more  commonly  encrusts  cal- 
culi of  some  other  species,  or  an  extraneous  body  which  acts  as 
a  nucleus  (Fig.  46).  Concretions  of  this  substance  are  fre- 
quently formed  around  the  inequalities  of  fungous  or  other 
growths  of  the  urinary  organs.  Calculi  of  the  mixed  phos- 
phates may  go  on  increasing  for  an  indefinite  period,  and  com- 
pletely fill  the  bladder,  attaining  a  weight  of  10,  20,  or  even  30 
ounces.^ 

1  "  On  the  Influence  of  Colloids,"  etc.,  p.  135. 

^  Dr.  Utterhoeven,  of  Brussels,  withdrew,  by  the  suprapubic  operation,  from 
the  bladder  of  a  man,  aged  thirty-nine,  an  enormous  oval  concretion  weighing 
40J  ounces,  and  measuring  round  its  longest  diameter  17  inches.  I  believe  this 
is  the  largest  ever  extracted  from  a  living  person.  It  had  been  growing  from  the 
age  of  twelve.  (Leroy  d'EtioUes  (fils),  Traite  pratique  de  la  Gravelle.  Paris, 
1863.) 


VARIETIES    OF    URINARY    GRAVEL    ANJJ    CALCULI. 


507 


In  their  physical  cliaractors,  fusible  calculi  most  resemble  the 
bone-earth  phosphate.  They  are  usually  lax  and  friable,  com- 
posed of  concentric  laminfe,  or  irrei^ular;  often  studded  on  the 
surface  with  brilliant  glistening  i^oints  of  triple  phosphate  crys- 
tals. They  readily  break  down  under  the  lithotrite;  but  the 
general  irritation  of  the  system,  and  the  frequent  coexistence 


Fio.  40. 


■^%% 


Section  of  a  concretion, 


if  a  vast  mass  of  tlie  mixed  pliosphates  deposited  on  a  calculus 
of  oxalate  of  lime.' 


of  grave  anatomical  lesions  in  the  urinary  passages  or  the  kid- 
neys, render  these  cases  unfavorable  subjects  for  operation. 
They  are  especially  suited  for  a  solvent  treatment  by  means  of 
acid  injections,  thrown  into  the  bladder  in  the  manner  recom- 
mended by  Sir  B.  Brodie. 

Chemically,  this  concretion  is  characterized  by  fusing  into^an 
enamel  when  strongly  urged  by  the  blowpipe.  It  is  very  soluble 
in  acids,  especially  the  mineral  acids ;  but  wholly  insoluble  in 
water  and  alkalies. 

10.  FiBRiNE  AND  Blood  CONCRETIONS. — Marcct  givcs  an  ac- 
count of  a  small  calculus  about  the  size  of  a  large  pea,  which 
was  passed,  after  much  suffering,  by  a  gentleman  between  50 
and  55  years  of  age.  He  had  been  suffering  for  two  or  three 
years  from  symptoms  of  urinary  calculi,  and  had  previously 
passed  three  similar  concretions.  The  specimen  examined  by 
Marcet  had  a  yellowish-brown  color,  somewhat  resembling  bees- 
wax. Its  hardness  was  also  nearly  that  of  beeswax.  Its  surface 
was  uneven,  but  not  rough  to  the  touch;  it  was  somewhat  elas- 

1  From  a  drawing  in  tlie  possession  of  Sir.  Southam.  The  history  of  this  stone 
(which  was  successfully  removed  by  the  recto-vesical  operation)  is  given  by  3Ir. 
Southam  in  the  42d  vokime  of  the  Medico-Chirurgical  Transactions. 


308  GRAVEL    AND    CALCULUS. 

tic.  When  examined  chemically,  it  answered  to  the  reactions 
of  fibrine. 

A  concretion,  about  the  size  of  a  small  pea,  was  handed  to 
me  for  examination  by  my  late  colleague,  Mr.  Beever.  It  had 
been  passed  by  a  man  of  thirty-five,  whose  urine  was  not  albu- 
minous. Its  texture  was  hard  and  brittle,  its  external  surface 
rough,  its  color  dark  reddish-brown.  It  swelled  into  a  volumi- 
nous coal  under  the  blowpipe,  and,  when  fully  incinerated,  left 
a  very  scanty  white  ash.  It  was  evidently  composed  of  inspis- 
sated blood. 

A  patient  whom  I  saw  with  Dr.  Holland  was  in  the  habit  of 
passing  numbers  of  blood  concretions  of  a  softer  texture.  He 
had  previously  suffered  from  hsematuria. 

]SI"umerous  similar  concretions  were  found  loose  in  the  infun- 
dibula  and  pelvis  of  the  kidney,  in  the  case  of  ruptured  kidney 
already  described  at  p.  153. 

My  collection  contains  a  very  fine  blood  concretion,  taken 
from  the  bladder  of  a  sheep  (Fig.  47).     The  specimen  was  pre- 

FiG.  47. 


Blood  concretion  from  the  bladder  of  a  sheep. 

sented  to  me  by  Mr.  Lund.  It  is  as  large  as  a  small  walnut, 
very  light — weighing  only  37  grains.  It  is  nearly  spherical,  and 
exceedingly  rugged  on  the  surface,  which  is  studded  all  over 
with  reddish-black  warty  projections.  This  dark  warty  part 
forms  the  outer  crust  of  the  concretion,  is  very  brittle,  and 
breaks  with  a  lustrous  fracture.  When  sawed  through,  the  rough 
outside  crust  is  found  to  be  about  a  line  thick :  it  invests  an 
oval  body,  which  has  an  even,  sharply  defined  outline.  The 
body  has  the  appearance  of  baked  clay;  it  is  of  nut-brown  color, 
and  easily  scraped  with  the  nail.  It  breaks  with  a  dull  fracture, 
like  a  piece  of  catechu.  Examined  chemically  and  microscopic- 
ally, both  body  and  crust  were  found  to  possess  the  characters 
of  concrete  blood.  The  scanty  ash  obtained  by  calcination  gave 
abundant  evidence  of  iron. 

All  these  instances  appear  to  have  been  connected  with  the 
occurrence  of  renal  hsematuria.  Such  concretions  sometimes 
serve  as  nulclei  for  uric  acid  or  oxalate  of  lime  calculi.^ 

1  Wilson's  Lectures  on  the  Urinary  Organs,  p.  81. 


DIAGNOSIS    OF    TJIK    HPECIKS.  309 

11.  Indigo. — Only  one  example  of  calculus  composed  solely 
of  indigo  is  known.  It  was  described  by  Dr.  Ord  in  the 
"Pathological  Transactions,"  vol.  xxix.,  and  was  found  in  the 
pelvis  of  the  riglit  kidney  of  a  woman,  who  had  died  from  a 
sarcomatous  tumor  of  the  left  kidney.  The  calculus  was  flat 
and  hard,  and  weighed  40  grains.  Its  color  was  dark  brown  in 
some  parts,  in  others  blue-black,  and  it  left  a  blue-black  mark 
when  drawn  across  a  sheet  of  white  paper.  On  heating  it  gave 
off  the  odors  of  burnt  indigo,  and  sublimed  in  blue  prisms  of 
indigo. 

12.  Prostatic  Calculi. — Although  these  are  not,  strictly 
8pea]<ing,  urinary  products,  they  are  in  very  rare  instances  dis- 
charged spontaneously  with  the  urine,  and  therefore  deserve 
some  notice  in  this  connection. 

Sir  H.  Thompson,  who  has  investigated  this  subject  with  great 
care,  states  that  the  existence  of  concretions  in  the  prostate  is 
almost  universal  after  the  age  of  puberty.  He  found  them  in- 
variably present  in  seventy  prostates  which  he  examined  from 
persons  above  twenty.^ 

They  begin  as  minute,  globular,  transparent  bodies  in  the 
follicles  of  the  gland.  At  first,  they  are  wholly  composed  of  an 
albuminous  matter,  arranged  in  concentric  layers  around  a  vesi- 
cular nucleus.  But  as  they  grow,  they  are  gradually  more  and 
more  impregnated  with  mineral  matter,  until  at  length  they  at- 
tain the  hardness  of  the  hardest  urinary  calculi.  As  a  rule,  they 
produce  no  symptoms,  and  their  existence  is,  perhaps,  hardly  to 
be  looked  on  as  a  disease.  They  usually  vary  in  size  from  a 
poppy  seed  to  xoVo  ^^  ^^  inch. 

In  some  cases,  however,  the  process  does  not  stop  here.  The 
earthy  material  is  deposited  in  great  quantity ;  and  large  concre- 
tions are  formed,  which  encroach  on  the  glandular  tissue,  and 
project  into  the  urethra  in  the  form  of  oblong  masses,  which  re- 
quire operative  procedures  for  their  removal. 

ON  THE  DIAGNOSIS  OF  THE  SPECIES  OF  UKINAKT  CALCULI 
WITHIN  THE  BLADDEE  OR  KIDNEY. 

It  would  greatly  facilitate  the  choice  of  the  most  appropriate 
treatment,  in  an  individual  case  of  urinary  calculus,  if  it  were 
possible  to  ascertain  beforehand  the  exact  nature  of  the  concre- 
tion. This  remark  applies  equally  to  surgical  and  to  medical  treat- 
ment, but  more  strongly  to  the  latter  than  to  the  former. 

The  degree  of  precision  of  this  knowledge  attainable  in  dif- 
ferent cases  varies  a  good  deal.  The  most  certain  knowledge  is 
gained  when  a  person  who  has  been  in  the  habit  of  sponta- 

'  Sir  H.  Thompson,  On  the  Enlarged  Prostate. 


310  GRAVEL    AND    CALCULUS. 

neously  voiding  small  concretions  becomes  afterwards  the  sub- 
ject of  stone.  In  such  a  case,  the  examination  of  the  calculi 
previously ,  passed  (supposing  them  to  have  been  preserved) 
throws  a  sure  light  on  the  nature  of  the  one  retained — provided 
the  epoch  at  which  the  former  were  voided  be  not  too  remote, 
and  the  characters  of  the  urine  continue  to  correspond. 

In  the  absence  of  this  kind  of  evidence,  certain  knowledge  of 
the  nature  of  the  stone  is  often  unattainable ;  but  still,  it  is  gen- 
erall}^  possible  to  indicate — from  the  character  of  the  urine,  the 
microscopic  examination  of  the  urinary  deposit,  the  constitution 
of  the  patient,  and  the  known  relative  frequency  of  the  several 
species  of  stone — loith  strong  probabiliti/,  the  species  to  which  it 
belongs;  and  also  (and  with  still  greater  certainty)  some  of  the 
species  to  which  it  does  not  belong.' 

With  regard  to  the  character  of  the  urine,  the  most  important 
indications  are  supplied  by  the  nature  of  its  reaction,  and  the 
character  of  the  deposit  which  may  be  precipitated  from  it. 
The  reaction  of  the  urine  may  be  (a)  acid;  (b)  alkaline  from 
fixed  alkali;  or  (c)  alkaline  from  carbonate  of  ammonia. 

a.  If  the  urine  be  acid,  the  stone  is  almost  sure  to  be  uric  acid 
or  oxalate  of  lime,  or  a  mixture  of  these  two.^  These  two 
deposits  alternate  wdth  each  other  so  frequently,  and  at  such 
short  intervals,  that,  if  the  urine  be  free  from  a  uric  acid  or  an 
oxalate  of  lime  sediment,  there  is  nothing  to  indicate  directly 
which  of  the  two  species  the  stone  belongs  to.  But,  as  uric 
acid  is  much  more  common  than  oxalate  of  lime,  the  probabili- 
ties are  considerably  in  favor  of  the  former.  If  the  urine,  on 
cooling,  deposits  abundantly  either  uric  acid  or  oxalate  of  lime, 
and  a  fortiori,  if  either  of  these  deposits  is  found  in  the  urine 
at  the  moment  of  emission,  there  is  strong  probability  that  the 
surface  oi  the,  stone  is  of  the  same  nature;  but  this  gives  no 
warrant  of  the  composition  of  the  deeper  strata. 

Vesical  calculi  are  usually  more  complex  in  their  composition 
than  renal  calculi.  The  latter  are  almost  always  composed  of 
one  single  ingredient ;  but  the  former  are  frequently  composed 
of  more  than  one  ingredient.  The  longer  a  calculus  has  resided 
in  the  bladder,  the  more  complex  will  its  composition  probably 
be;  and  conversely,  the  more  recent  its  descent  from  the  kidney, 
the  more  likelihood  that  it  is  composed  of  but  a  single  ingredient. 
If,  therefore,  the  urine  be  acid,  and  the  calculus  of  recent  date, 
the  probabilities  are  greatly  increased  that  it  is  composed  of 
uric  acid  alone. 

1  For  the  diagnosis  of  renal  calculi  and  of  their  chemical  constitution,  see 
Chapter  VII. 

2  Concretions  of  xanthine,  fibrine,  and  fatty  matters  are  altogether  left  out  of 
consideration,  on  account  of  their  extreme  rarity.  Cystine  is  also  excessively  rare  ; 
and  if  cystine  crystals  be  not  found  in  the  deposit,  it  may,  practically,  be  like- 
wise excluded. 


MEDICAL    TREATMENT.  811 

As  mulberry  calculi  have  rough  surlaccs,  they  usually  produce 
more  violent  irritation  of  the  bhidder  than  the  smoother  stones 
composed  of  uric  acid.  This  indication  is,  however,  of  little 
practical  value,  and  the  exce[)tions  to  it  are  immerous. 

Persons  of  gouty  disposition  are  more  likely  to  be  subjects  of 
uric  acid  than  of  oxalate  of  lime  calculi. 

b.  If  the  urine  be  alkaline  from  fixed  alkali^  the  stone  will  be 
composed  either  of  bone-earth  phosphate  oi  carbonate  of  lime. 
Both  are  of  extreme  rarity. 

c.  If  the  urine  be  alkaline  from  carbonate  of  ammonia^  the  com- 
position of  the  nucleus  and  body  of  the  calculus  can  no  longer 
be  divined;  but  its  surface  or  crust  is  sure  to  be  composed  of 
the  mixed  phosphates.  The  depth  of  this  crust  can  only  be 
conjectured  from  the  intensity  of  the  ammoniacal  reaction,  the 
quantity  of  pus  and  flakes  vs^hich  are  discharged  with  the  urine, 
and  the  length  of  time  during  which  this  state  of  urine  has  per- 
sisted. Care  must  be  taken  to  ascertain  if  the  urine  be  ammo- 
niacal at  the  moment  of  emission;  for  in  most  cases  of  stone  there 
is  some  degree  of  cystitis;  and  the  presence  of  pus  causes  a 
urine  which  was  passed  acid,  speedily  to  become  ammoniacal. 
The  degree  of  the  ammoniacal  reaction  is  best  judged  of  by  the 
intensity  of  the  ammoniacal  odor,  by  the  gelatinized,  or  loose, 
condition  of  the  pus,  and  bj^  the  abundance  of  triple  phosphate 
crystals.  If  the  urine  be  only  very  feebly  ammoniacal,  or  have 
only  recently  become  ammoniacal,  the  phosphatic  crust  may  be 
only  a  thin  film.  In  the  case  of  large  or  old  phosphatic  concre- 
tions, fragments  of  phosphatic  debris  are  frequently  voided  with 
the  urine.  If  the  ammoniacal  reaction  of  the  urine  is  once 
established  in  a  case  of  stone,  it  seldom  afterwards  gives  place 
to  an  acid  reaction. 

MEDICAL  TREATMENT  OF  GRAVEL  AND  CALCULI. 

Two  objects  are  to  be  held  in  view  in  the  medical  treatment 
of  gravel  and  calculi,  namel}^  (A),  to  prevent  the  formation  of  a 
concretion  wdien  a  tendency  thereto  exists;  and  (B)  to  dissolve 
or  facilitate  the  expulsion  of  concretions  already  formed.  The 
treatment  of  the  organic  lesions  which  are  incidental  to  the 
presence  of  calculi  in  the  urinary  passages  will  be  considered — 
in  so  far  as  they  implicate  the  kidneys  and  their  immediate  ap- 
pendages— in  Part  III.  with  the  other  organic  afteetions  of  the 
kidneys. 

(A)  Preventive  Treatment. 

The  disposition  to  the  production  of  gravel  and  stone  gener- 
all}^  passes  by  undetected,  until  a  concretion  is  actually  formed. 
The  general  health  is,  usually,  not  markedly  disturbed,  and  the 


312  GRAVEL    AND    CALCULUS. 

local  symptons  only  attract  attention  when  the  urinary  passages 
begin  to  resent  the  presence  of  the  foreign  body. 

Sometimes,  however,  the  practitioner  becomes  aware  before- 
hand, from  the  character  of  the  urine  or  other  circumstances, 
that  the  formation  of  a  stone  is  a  probable  event  unless  preven- 
tive means  be  adopted. 

The  occurrence  of  a  deposit  of  uric  acid  or  oxalate  of  lime, 
after  the  urine  has  stood  some  hours,  indicates  no  special  risk  of 
the  formation  of  a  stone;  but  if  either  of  these  substances  be 
voided  with  the  urine,  as  gravel,  such  a  risk  does  certainly  exist, 
and  demands  to  be  provided  for.  Again,  if  the  urine,  although 
clear  when  voided,  lets  fall  a  crystalline  deposit  before  it  has  com- 
fletely  cooled,  as  may  sometimes  be  seen,  especially  in  children, 
the  danger  of  a  formation  of  stone  should  not  be  overlooked. 
The  presence  of  cystine  in  the  urine  is,  at  all  times,  a  circum- 
stance which  demands  precautions  against  the  formation  of  a 
calculus.  The  existence  of  an  ammoniacal  state  of  the  urine, 
also,  always  involves  a  risk  of  the  deposition  of  the  secondary 
phosphates. 

Independently  of  the  existing  state  of  the  urine,  evidence  of 
a  calculous  tendency  is  sometimes  obtained  from  the  antecedents 
of  the  patient.  If  the  patient  have  recently  voided  a  concre- 
tion with  the  urine,  or  if  one  have  been  removed  from  his 
bladder  by  surgical  operation,  there  is  reason  to  apprehend  a 
continuance  of  the  calculous  tendency,  and  the  formation  of  a 
new  concretion. 

Under  any  of  these  circumstances,  preventive  measures  are 
demanded.  These  may  be  divided  into  general  and  special.  The 
former  apply  to  calculous  tendencies  of  every  kind;  the  latter  to 
threatened  formation  of  some  particular  species  of  stone. 

Among  the  general  indications,  the  most  important  is  to 
obviate  undue  concentration  of  the  urine.  This  is  effected  by 
the  systematic  use  of  increased  quantities  of  aqueous  drinks. 
The  urine  is  apt  to  reach  the  greatest  degree  of  concentration 
at  hours  remote  from  meal-times  (especially  during  the  two  or 
three  hours  which  precede  a  late  dinner),  and  during  the  hours 
of  sleep.  At  these  periods  the  flow  of  the  urine  is  exceedingly 
scanty;  it  is  long  delayed  in  the  bladder  before  there  is  any  call 
for  its  evacuation ;  its  solid  constituents  are  in  excessive  propor- 
tion to  the  watery  parts,  so  that  the  urine  resembles  a  supersatu- 
rated saline  solution;  it  is  also  very  acid.  Here  are  united  all 
the  conditions  most  favorable  to  the  separation  of  some  of  its 
less  soluble  components.  Dr.  Prout  pointed  out  that  the  re- 
cumbent posture  during  sleep  furnished  an  additional  source  of 
apprehension,  inasmuch  as  the  urine  is  no  longer  aided  in  its 
descent  by  the  force  of  gravity;  it  therefore  lingers  and  accumu- 


MEDICAL    TKKATMENT.  318 

lates  in  the  pelvis  of  the  kidney,  and  h  lialde  to  depoHit  Bomc  of 
its  constituents  therein. 

All  these  untoward  contingencies  are  obviated  by  tbe  simple 
expedient  of  taking  a  tumbler  of  water  a  coujjle  of  hours  before 
dinner,  and  another  before  retiring  to  rest.  By  tliis  means  the 
urine  is  diluted,  and  its  escape  hastened  at  the  periods  when  it 
would  otherwise  be  dangerously  saturated,  and  unduly  delayed 
in  the  excretory  conduits.  Two  other  points  are  worthy  of  at- 
tention, with  a  view  of  maintaining  the  urine  in  a  state  of  safe 
dilution,  and  providing  for  its  undelayed  expulsion.  These  are  : 
first,  that  a  too  great  interval  shall  not  elapse  between  any  two 
meals;  and,  secondly,  that  the  period  devoted  to  rest  in  bed 
shall  not  be  too  prolonged.  From  observations  recorded  in  a 
previous  page,  it  is  seen  that  a  meal  both  renders  the  urine  more 
abundant,  and  lessens  its  acidity.  An  individual  who  shows  a 
tendency  to  calculous  formations  should,  therefore,  be  directed 
to  take  four  or  five  light  meals  during  the  day,  at  about  equal 
intervals,  and  to  arise  betimes  in  the  morning. 

When  the  nature  of  the  calculous  tendency  is  ascertained, 
either  from  the  character  of  the  deposit,  or  from  the  composi- 
tion of  a  previously  voided  concretion,  further  and  special  pre- 
cautions should  be  recommended. 

If  the  tendency  be  to  the  precipitation  of  tiric  acid,  the  acidity 
of  the  urine  should  be  lowered  by  the  moderate  employment  of 
the  bicarbonate  or  citrate  of  potash.  A  drachm  of  either  salt 
may  be  taken  in  a  tumbler  of  water  at  bed-time,  and  again  on 
rising  in  the  morning.  The  diet  should  be  regulated  in  such 
manner  that  animal  flesh  shall  not  form  a  too  prominent  part  of 
it.  Rich  wines  and  heavy  meals  must  be  strictly  prohibited,  and 
a  bland,  mostly  farinaceous,  diet  substituted. 

The  deleterious  effects  of  high  diet  on  uric  acid  gravel,  is 
aptly  illustrated  in  an  example  furnished  by  Magendie: 

Mr. ,  a  merchant  in  one  of  the  Hanseatic  cities,  possessed  in  1814 

an  ample  fortune,  and  he  lived  in  accordance  with  his  means — kept  a 
good  table,  and  indulged  in  its  pleasures  freely.  He  was  at  this  time 
tormented  with  gout  and  gravel.  Unexpectedly,  he  lost  all  his  fortune 
through  a  political  crisis,  and  was  obliged  to  take  refuge  in  England, 
where  he  lived  more  than  a  year,  almost  in  poverty,  amid  numerous 
privations ;  but  his  gravel  completely  disappeared.  Little  by  little  he 
succeeded  in  repairing  his  affairs ;  he  resumed  his  old  mode  of  life,  and 
the  gravel  was  not  long  in  reappearing.  A  second  reverse  robbed  him 
in  a  short  time  of  all  he  had  gained.  He  passed  into  France  almost 
without  resources,  and  his  regimen  was  consonant  to  his  means ;  the 
gravel  disappeared.  Once  again  his  industry  restored  him  to  a  life  of 
plenty  and  ease ;  he  abandoned  himself  again  to  the  indulgences  of  the 
table,  and  with  them  appeared  once  more  his  old  enemy  the  gravel.^ 

1  Magendie,  De  la  Gravelle,  p.  25. 


314  GRAVEL    AND    CALCULUS. 

The  special  preventive  treatment  of  cystine  concretions  is 
identical  with  that  of  uric  acid. 

With  regard  to  oxalate  of  lime,  the  principal  indications  are,  to 
dilute  the  urine  by  abundant  regulated  potation  of  aqueous 
drinks,  and  to  encourage  the  action  of  the  skin  by  baths,  fric- 
tions, the  use  of  flannel  clothing,  and  exercise  in  the  open  air. 
It  is  important  also  to  guard  against  the  use  of  certain  vege- 
tables which  contain  large  quantities  of  oxalates  and  superoxa- 
lates  in  their  tissues.  The  general  use  of  rhubarb  tarts  in  this 
countr}^  in  the  spring  months,  and  the  use  of  sorrel  as  salad  in 
France,  are  probably  frequent  causes  of  oxalate  of  lime  concre- 
tions. Magendie  records  two  cases  in  which  it  appeared  highly 
probable  that  mulberry  calculi  had  been  produced  by  the  daily 
use  of  sorrel  (loc.  cit.  p.  121).  Both  these  articles  should  be  abso- 
lutely forbidden. 

Mineral  and  potable  waters,  which  are  rich  in  lime  should 
likewise  be  avoided. 

Heller  recommends  alkaline  substances,  on  the  grounds  that 
oxalate  of  lime  long  digested  with  alkaline  carbonates  is  re- 
solved into  a  soluble  oxalate,  and  that  uric  acid  is  the  source  of 
the  oxalic  acid  which  appears  in  the  urine.  Experiments  per- 
formed by  myself  on  mulberry  calculi,  yielded  no  evidence  that 
the  alkaline  carbonates  exert  any  solvent  action  thereon.  As  to 
the  second  point,  alkalies  do-  not  prevent  undue  formation  of 
uric  acid,  but  merely  facilitate  its  elimination.  JSTevertheless,  I 
have  seen  instances  in  which  rendering  the  urine  freely  alkaline, 
caused  an  oxalate  of  lime  deposit  to  disappear  temporarily  from 
the  urine. 

Basic  ])hosphate  of  lime  and  carbonate  of  lime  (unmixed  with 
triple  phosphate)  are  among  the  rarest  forms  of  urinary  calculi. 
Against  them,  the  proper  precautionary  measures  are,  to  en- 
deavor to  remove  the  alkalescence  of  the  urine  by  the  exhibition  of 
carbonic  acid  water,  and  to  exclude  as  much  as  possible  all 
articles  of  food  and  drink  which  are  rich  in  calcareous  salts. 

The  precipitation  of  the  secomlari/  phosphates  frequently  re- 
quires precautionary  measures  to  prevent  calculous  concretions. 
If  severe  cystitis  follow  lithotomy  or  lithotrity,  there  is  cause  to 
fear  a  deposition  of  phosphatic  matter  upon  some  fragment  left 
in  the  bladder,  or  on  a  mass  of  inspissated  pus  and  mucus. 
Indeed,  whenever  the  urine  is  highly  ammoniacal,  the  same 
danger  is  not  remote.  To  guard  against  it,  the  irritation  of  the 
bladder  should  be  allaj^ed  by  appropriate  means,  and  the  viscus 
should  be  thoroughly  washed  out,  at  least  twice  a  week,  with 
water,  or  with  a  solution  containing  a  drachm  of  the  commercial 
muriatic  acid  to  a  pint  of  water. 


MEDICAL    TKEA'J'MEN'J'.  315 


(B)     SOLVIONT    TliEATMKNT. 


For  therapeutical  purposes,  urinary  calculi  rimy  he  divided 
into  two  classes,  viz.,  those  which  are  soluble  in  alkalies,  and  those 
which  are  soluble  in  acids.  To  the  former  category  helong  uric 
acid,  the  urates,  and  cystine;  to  the  latter,  phosphatic  and  n^iul- 
berry  calculi.  Those  which  are  soluble  in  alkalies  may  (con- 
ceivably) be  attacked  by  alkalizing  the  urine  by  means  of  certain 
salts  administered  by  the  mouth,  or  by  injecting  alkaline  solu- 
tions into  the  bladder.  Those  which  are  soluble  in  acids  can 
only  be  attacked  by  the  latter  method,  inasmuch  as  acids  can- 
hot  be  made  to  pass  through  the  kidneys,  save  in  insignificant 
proportions.^ 

It  will,  however,  be  shown  in  the  sequel,  that  alkaline  sub- 
stances used  in  the  way  of  injections,  act  so  feebly  on  uric  acid 
calculi,  that  no  useful  results  can  be  expected  from  their  opera- 
tion ;  also  that  mulberry  calculi  are  unassailable  by  an}'  solvent 
method  hitherto  proposed ;  so  that  the  solvent  treatment  of  uri- 
nary calculi  resolves  itself,  practically,  into  two  lines  of  action, 
viz.,  attacking  uric  acid  calculi  (and  their  congeners),  by  alka- 
lizing the  urine  by  means  of  medicines  administered  internally, 
and  phosphatic  calculi,  by  injecting  acid  solutions  into  the 
bladder. 

It  is  a  noteworthy  fact,  that  alkaline  substances  had  obtained 
an  extended  reputation  in  the  treatment  of  calculous  disorders, 
long  before  the  composition  of  urinary  calculi  had  been  dis- 
covered. In  1739,  a  remed}'  of  this  class  —  the  nostrum  of 
Joanna  Stephens — made  so  great  a  noise,  that  Parliament  ap- 
pointed a  commission  of  professional  men  to  inquire  into  its 
virtues.  The  commission  reported  favorably,  and  a  reward  of 
£5000  was  assigned  to  Miss  Stephens  for  the  secret  of  its  com- 
position. The  active  ingredients  in  this  nostrum  were  burnt 
egg-shells  and  snails,  with  Alicant  soap.  As  soon  as  the  secret 
was  divulged,  soap,  soap-ley  (solution  of  caustic  potash),  and 
lime-water,  were  tried  in  all  kinds  of  calculous  cases.  The  in- 
discriminate use  of  the  remedies  led,  as  might  have  been  antici- 
pated, to  contradictory  results.  Both  successes  and  failures 
were   published   in    large    numbers;^   and    opinion  was   much 

^  Various  attempts  have  also  been  made  to  apply  galvanism  to  the  solution  of 
stones  in  the  bladder.  It  was  ingeniously  conceived  that  the  decomposition  of  a 
solution  of  nitrate  of  potash  within  the  bladder,  by  a  galvanic  current,  would  set 
free,  simultaneously,  both  nitric  acid  and  caustic  potash — one  or  other  of  which  is 
capable  of  acting  on  every  variety  of  stone.  But  the  mechanical  difficulties  of 
this  proceeding  have  hitherto  proved  insurmountable ;  and  the  slow  action  which 
my  experiments  prove  solutions  of  caustic  potash  to  have  on  uric  acid  calculi,  and 
solutions  of  uric  acid  on  mulberry  calculi,  render  it  hopeless  ever  to  obtain  results 
of  practical  utility  by  this  method.     -See,  also.  Heller's  Harnconcretionen,  p.  99- 

^  Ploucquet  gives  a  list  of  more  than  forty  papers  and  pamphlets,  published  on 
the  subject  about  1740. 


316  *      GRAVEL    AND    CALCULUS. 

divided  as  to  their  utility.  About  this  time  the  successes  of 
Cheselden  gave  a  great  impulse  to  lithotomy,  and  the  use  of 
solvents  gradually  fell  into  discredit.  The  subject  was  resus- 
citated in  France  about  a  century  later,  under  the  inspiration  of 
the  great  advances  then  made  in  chemical  science,  and  especially 
of  the  discoveries  of  Wollaston  and  Fourcroy  into  the  nature 
and  composition  of  urinary  calculi.  The  virtues  of  the  alkaline 
bicarbonates — and  more  particularly  of  the  bicarbonate  of  soda, 
the  active  ingredient  of  the  Vichy  springs — were  brought  into 
prominence ;  and  a  considerable  number  of  cases,  successfully 
treated  by  these  means,  were  published  by  Chevallier  and  Ch. 
Petit.  But  again,  the  absurd  claim  of  universal  efficacy  brought 
the  solvent  treatment  into  contempt;  and  for  the  last  twenty 
years,  or  more,  urinary  calculi  have  been  almost  wholly  aban- 
doned to  the  surgeon. 

A  perusal  of  the  literature  of  these  two  periods,  however, 
strongly  suggested  the  desirability  of  subjecting  the  question  to 
a  new  examination,  with  a  view  of  ascertaining  the  causes  of 
the  discrepant  experience  of  past  times;  and  also  of  indicating 
with  some  approach  to  certainty,  what  may  be  rationally  ex- 
pected from  a  solvent  treatment,  in  what  cases  it  is  applicable, 
and  the  precise  mode  of  carrying  it  out  eiiectually. 

For  the  purpose  of  clearing  up  these  questions,  the  present 
writer  undertook  an  extensive  series  of  experiments,  and  made 
numerous  clinical  observations.  The  facts  observed  are  em- 
bodied in  a  paper  read  before  the  Medical  and  Chirurgical 
Society,  on  March  28,  1865.  To  this  paper  the  reader  is  re- 
ferred for  fuller  details.  The  results  obtained  seem  to  demand 
a  considerable  modification  of  the  prevailing  opinion  regarding 
the  inutility  of  the  solvent  treatment.  The}'  do  not  by  any 
means  indicate  the  general  possibility  of  substituting  a  solvent 
for  a  mechanical  treatment  of  vesical  calculi;  but  they  suggest 
an  essential  improvement  in  the  treatment  oi renal  calculi;  they 
also  indicate  that  uric  acid  calculi,  under  certain  circumstances, 
are  capable  of  solution  in  the  bladder,  by  means  of  alkaline 
salts  administered  by  the  mouth,  at  a  rate  which  admits  of 
practical  application ;  and  that,  in  certain  picked  cases  of  this 
class,  a  solvent  treatment  deserves  to  be  resolutely  tried,  before 
having  recourse  to  the  more  dangerous  methods  of  lithotomy 
and  lithotrity. 

Attention  was  naturally  directed  in  the  iirst  instance,  and 
chiefly,  to  uric  acid,  both  on  account  of  its  being  by  far  the 
most  common  constituent  of  urinary  calculi,  and  also  on  account 
of  its  offering  the  greatest  probabilities  of  success.  But  the 
inquiry  was  not  altogether  confined  to  uric  acid:  experiments 
were  also  made  on  the  solubility  of  cystine,  oxalate  of  lime,  and 
phosphatic  calculi. 


MEDICAL    TREATMENT.  317 

On  the  Solvent   Treatment  af  Uric  Acid  by  the  Admmistration  of 
Alkaline  Salts  by  the  Mouth. 

The  inquiry  respecting  uric  acid,  set  out  from  two  known 
data,  viz. : 

J^rst. — That  sohitions  of  the  alkaline  carbonates  exercise  a 
solvent  action  on  uric  acid. 

Second. — That  the  urine  can  be  rendered  alkaline  from  alka- 
line carbonates  by  the  administration  of  certain  salts  by  the 
mouth. 

Starting  from  these  data,  a  number  of  preliminary  questions 
immediately  presented  themselves,  which  it  was  necessary  to 
answer  before  proceeding  to  the  more  practical  part  of  the 
inquiry.  These  were:  1.  Whether  is  carbonate  of  potash  or 
carbonate  of  soda^  the  better  solvent  for  uric  acid  ?  2.  What 
is  the  best  strength  of  solution  to  employ.  3.  What  is  the 
effect  of  varying  quantities  of  the  solution  on  the  results  ob- 
tained? 

Answers  to  these  questions  were  sought  by  placing  sections 
of  uric  acid  calculi  usually  weighing  about  100  grains,  in  10  oz. 
phials,  and  causing  currents  of  the  different  solutions,  at  blood 
heat,  to  pass  over  them  at  a  regulated  rate. 

1.  With  regard  to  the  comparative  solvent  jpoioers  of  carbonate  of 
•potash  and  carbonate  of  soda,  the  experiments  indicated  clearly 
that  potash  dissolved  uric  acid  more  rapidly  than  soda.  A  solu- 
tion of  carb.  potash,  containing  30  grains  to  the  pint,  dissolved 
daily  11.9  per  cent,  of  a  uric  acid  calculus;  while  a  solution  of 
carb.  soda  of  equal  strength,  dissolved  only  10.3  per  cent.  The 
potash  salt  possessed  a  further  advantage  in  its  wider  range  of 
solvent  power  with  the  stronger  solutions.  This  latter  point 
will  be  better  understood  after  the  effects  of  solutions  of  differ- 
ent strength  have  been  considered  in  the  next  paragraph. 

2.  The  Strength  of  the  Solution  was  found  to  affect  its  solvent 
capacity  more  than  any  other  condition.  It  soon  became  ap- 
parent that  only  very  weak  solutions  could  yield  any  useful  results. 
The  greatest  solvent  power  was  found  to  reside  in  solutions  con- 
taining from  40  to  60  grains  of  carbonate  to  the  imperial  pint. 
Below  this  strength,  the  power  of  the  solutions  gradually  de- 
clined, until,  with  solutions  containing  less  than  three  grains  to 
the  pint,  the  solvent  power  only  slightly  exceeded  that  of  ordi- 
nary water.  On  the  other  hand,  with  solutions  above  the 
strength  of  60  grains  to  the  pint,  dissolution  was  impeded,  and 

1  The  experiments  were  principally  directed  to  ascertain  the  effects  of  the  alka- 
line carbonates,  because  all  salts  which  have  the  power  of  alkalizing  the  urine  to 
a  useful  degree,  appear  in  the  urine  as  carbonates.  A  number  of  otlier  salts  were 
however  tried,  viz.,  neutral  and  alkaline  borates,  phosphates,  and  soaps. 


318 


GRAVEL    AND    CALCULUS. 


finally  arrested,  by  the  formation  of  a  white  crust  or  coat  of 
alkaline  biurate  on  the  surface  of  the  calculus.  With  a  solu- 
tion of  80  grains  to  the  pint,  this  biurate  crust  was  loose  and 
easily  detached,  like  a  layer  of  whitewash;  but  with  a  solution 
of  120  grains  to  the  pint,  the  crust  was  tenacious  and  adherent, 
and  very  little  dissolution  took  place  with  carbonate  of  potash, 
and  none  at  all  with  carbonate  of  soda.  With  solutions  of  160 
and  240  grains  to  the  pint,  there  was  no  less  of  weight  with 
potash  or  soda;  the  fragments  became  invested  with  a  thin  tough 
coating  of  white  biurate,  resembling  white  paint,  which  put  a 
stop  to  all  solvent  action.^ 

The  following  table  exhibits  the  results  obtained  with  solu- 
tions of  carbonate  of  potash  of  varying  strength: 


strength  of  solution. 

Daily  average  loss  of  weight 

240    grains  per  pint 0  per  cent. 

160 

0           " 

120 

3.0 

80 

9.8         "      ' 

60 

20.2 

40 

15.6 

30 

11.9 

20 

11.0 

10 

6.5 

5 

6.0 

2J 

2.8 

1 

1.2         "     . 

The  quantity  of  solution  permitted  to  flow  over  the  stone 
was,  generally,  six  pints  in  the  twenty-four  hours. 

3.  It  was  at  first  supposed  that  the  quantity  of  the  solution  per- 
niitted  to  flow  over  the  stone  would  greatly  influence  the  rate 
of  dissolution;  but  on  actual  trial,  the  efifect  of  quantity  within 
the  limits  necessarily  imposed  by  the  capacity  of  the  kidneys  to 
eliminate  fluids,  proved  to  be  comparatively  unimportant.  In 
order  to  obtain  comparable  results,  dififerent  quantities  of  a  solu- 
tion of  uniform  strength  were  passed  over  the  same  stone  on 
successive  days. 

A  solution  of  carbonate  of  potash  containing  thirty  grains  to 
the  pint,  gave  the  following  results : 


Daily  flow. 

15  pints 

8     " 

6     " 

4     " 


Daily  loss  of  weight. 

18.0  per  cent. 
15.0        " 
10.2        " 
9.5        " 


A  flow  of  even  one  or  two  pints  per  day,  with  a  solution  of 
suitable  strength,  produced  a  copious  dissolution.    Two  pints  of 

1  For  further  information  regarding  this  white  coating  of  biurate,  see  an  ab- 
stract of  a  paper  by  the  author  in  the  Trans,  of  the  Brit.  Assoc,  for  the  Adv.  of 
Science  for  1861 ;  also  Beale's  Archives  for  1862. 


MEDICAL    TREATMENT.  319 

a  solution  of  carbonate  of  potash,  containing  forty  grains  to  tlie 
pint,  caused  a  daily  dissolution  of  17.1  per  cent. 

4.  With  regard  to  the  ahsohde  rate  of  dissolution  attainable,  the 
experiments  opened  out  an  inviting  prospect.  The  solutions  of 
niaxiniuni  solvent  power  dissolved  from  ten  to  twenty  per  cent, 
of  tlie  calculi  in  the  course  of  twenty-four  hours.  If  results  aj)- 
proaching  these  could  be  obtained  in  the  living  body,  a  little 
consideration  will  show  that  such  an  impression  could  be  made 
on  a  uric  acid  concretion,  in  a  few  weeks  or  months,  as  would 
either  entirely  dissolve  it,  or  reduce  its  dimensions  to  a  ])oint 
which  would  enable  it  to  escape  spontaneously  by  the  natural 
passages. 

Having  disposed  of  these  preliminary  inquiries,  the  next 
points  to  be  ascertained  were:  the  best  way  of  alkalizing  the 
urine,  so  as  to  impart  to  it  an  alkalescence  corresponding  to  that 
of  solutions  of  carbonate  of  potash  of  maximum  solvent  power: 
also  to  examine  the  actual  effect  of  alkalized  urine  passed  over 
uric  acid  calculi,  in  a  phial,  at  blood  heat. 

5.  The  most  convenient  way  of  alkalizivg  the  urine  was  found 
to  consist,  in  giving  frequently  repeated  doses  of  the  acetate  or 
the  citrate  of  potash.  Both  these  salts  are  extremely  soluble; 
they  are  well  borne  by  the  stomach;  they  do  not  interfere  with 
digestion  nor  occasion  purging.  Weight  for  weight,  the  two 
salts  were  found  to  possess  nearly  equal  alkalizing  powers. 
With  some  individuals  the  acetate  agreed  better  that  the  citrate; 
with  others  the  converse  was  the  case. 

In  order  to  maintain  the  urine  at  a  degree  of  alkalescence 
that  should  correspond  to  the  maximum  solvent  power  of  solu- 
tions of  carbonate  of  potash  (/.  e.,  an  alkalescence  equal  to  about 
50  grains  of  carbonate  to  the  pint),  it  was  found  necessary,  in 
adults,  to  administer  from  40  to  50  grains  of  the  acetate  or 
citrate  of  potash,  dissolved  in  three  or  four  ounces  of  water, 
every  three  hours. 

It  was  found  quite  impossible  to  maintain  the  urine  at  an 
absolutely  constant  degree  of  alkalescence,  however  short  the 
intervals  at  which  the  dose  v>'as  repeated.  The  activity  of  the 
kidneys  oscillates  from  hour  to  hour;  at  one  time  the  urine  is 
secreted  abundantly  and  dilute,  and  then  the  degree  of  alka- 
lescence necessarily  falls ;  at  another  time  it  is  secreted  more 
scantily  and  more  concentrated,  and  then  the  degree  of  alka- 
lescence rises.  W^heu,  however,  the  above  dose  was  exhibited 
with  regularity,  every  second  or  third  hour,  the  oscillations 
rarely  passed  an  alkalescence  equivalent  to  20  grains  to  the  pint, 
on  the  one  hand,  and  80  grains  to  the  p^iut  on  the  other;  and,  as 
a  rule,  the  alkalescence  ranged  between  35  and  60  grains  to  the 
pint — which  corresponds,  sufficiently  exactly,  with  the  maxi- 
mum solvent  power  of  a  solution  of  carbonate  of  j)otash  in 
Avater. 


320  GRAVEL    AND    CALCU.LUS. 

6.  When  urine,  alkalized  by  the  internal  administration  of 
these  salts,  was  passed  over  the  surface  of  uric  acid  calculi,  at 
blood"  heat,  the  calculi  were  found  to  undergo  solution  at  the 
mean  rate  of  12|  grains  in  the  twenty-four  hours. 

In  performing  this  experiment  it  was  found  that,  unless  the 
calculus  and  the  phial  were  frequently  cleansed  by  immersion 
in  water,  the  urine  became  ammoniacal,  and  the  calculus  be- 
came covered  over  with  a  crust  of  the  mixed  phosphates,  which 
speedily  put  a  stop  to  the  solvent  action  of  the  alkalized  urine. 
An  important  practical  deduction  flowed  from  this,  viz.,  that 
when  an  ammoniacal  state  is  developed,  the  solvent  ■power  of  alkalized 
urine  is  entirely  nullified,  by  the  deposition  of  the  mixed  phosphates  on 
the  surface  of  the  calculus. 

The  urine  of  patients  taking  full  doses  of  the  citrate  or 
acetate  of  potash,  is  generally  clear,  and  shows  no  tendency 
to  deposit,  even  on  standing.  But  this  is  not  invariably  the 
case;  it  is  sometimes  turbid  from  deposition  of  the  amorphous 
phosphate  of  lime.  Two  conditions  seemed  specially  to  favor 
this  deposition,  namelj^,  the  febrile  state,  and  the  digestion  of  a 
heavy  meal.  The  amorphous  phosphate  is  not  unfrequently 
deposited,  as  we  have  already  seen  (p.  78),  after  a  meal,  in 
healthy  persons  who  are  not  taking  any  alkalizing  medicines; 
the  circumstance  is,  therefore,  not  to  be  regarded  as  an  un- 
natural or  hazardous  one.  It  is,  further,  to  be  borne  in  mind, 
that  the  amorphous  phosphate  differs  essentiallj  from  the  mixed 
phosphates  thrown  down  m  an  ammoniacal  urine.  The  former 
is  a  loose  flocculent  substance,  which  shows  no  tendency  to 
aggregate  into  concretions;  the  latter,  on  the  other  hand,  is 
partly  crystalline,  and  speedily  encrusts  any  object  brought  into 
contact  with  it.  The  establishment  of  this  distinction  disposes 
of  one  objection  which  has  been  urged  against  alkaline  solvents. 

It  now  remains  to  bring  forward  illustrations  of  the  applica- 
tion of  the  solvent  treatment  in  practice;  to  distinguish  the 
cases  in  which  the  treatment  is  applicable ;  to  lay  down  direc- 
tions for  carrying  it  out  effectually;  and,  finally,  to  examine 
some  of  the  objections  which  have  been  urged  against  its 
employment. 

7.  Illustrations  of  the  practical  employment  of  alkaline  sol- 
vents may  be  divided  into  cases  of  renal  calculi,  and  cases  of 
vesical  calculi. 

One  of  the  first  rational  attempts  to  treat  renal  gravel  of  uric 
acid  by  alkaline  solvents,  was  made  by  the  celebrated  Mascagni 
in  his  own  person.  He  gives  the  following  account  of  his  case 
in  the  "  Memoirs  of  the  Italian  Society  for  1804 :" 

I  had  been  subject  for  several  years  to  pains  in  the  lumbar  regions, 
and  I  voided  from  time  to  time  gravelly  concretions  of  a  yellow-ochre 


MEDICAL    TUEATMENT.  321 


and  brick-red  color.  Knowing  that  gaseous  alkaline  flmds  l.acl  been 
used  in  such  cases,  I  took  some  on  several  occasions  with  beneht.  1 
iina<rined  I  could  obtain  greater  effects  with  carbonate  ot  potasli. 

Ju  the  months  of  August  and  September,  1709,  having  been  o])l,ged 
to  lead  a  sedentary  life,  I  was  cruelly  attacked  with  pains  in  the  kid- 
neys, and  I  voided  a  considerable  number  of  small  concretions,  some  ot 
which  were  large  enough  to  be  regarded  as  ver.tab  e  calculi.  Ihey 
were  reddish  and  crystalline;  they  were  deposited  at  the  bottom  ot  the 
vessel  each  time  I  made  water,  and  I  could  see  their  glistening  facets 
through  the  transparent  urine.  I  was  also  subject  to  ari  excess  ot  acid 
in  the  stomach,  which  was  perceived  in  the  mouth.  I  examined  my 
urine  and  found  in  it  a  free  acid,_which,  as  well  as  the  concretions,! 
recognized  as  consisting  of  uric  acid. 

Having  thus  assured  myself  of  the  nature  of  the  concretions  1  was 
voidino-  I  resolved  to  make  use  of  the  carbonate  of  potash  and  to 
observe  the  result.  I  took  the  first  day  about  a  drachm,  one-half  in 
the  morning  fasting,  and  the  other  half  in  the  evening.  I  dined  at  one 
o'clock  in  the  afternoon.  This  salt  dissolved  in  ten  ounces  of  wa  er  had 
very  little  taste,  it  caused  no  disturbance  of  the  stomach  or  bowels ;  but 
as  soon  as  I  swallowed  it,  it  occasioned  a  considerable  disengagement 
of  carbonic  acid  gas,  which  was  felt  in  the  mouth  and  discharged  by 


the  anus 


The  second  day  I  took  two  drachms,  and  the  third  day  three  drachms ; 
and  I  continued  this  dose,  dissolved  in  twenty  ounces  pf  water,  for  ten 
days.  Before  using  the  carbonate  my  urine  was  very  acid,  and  intensely 
reddened  blue  litmus  paper.  On  the  second  day  the  paper  changed 
color  very  little,  and  none  at  all  on  the  third  day.  The  acid  of  my 
urine  was  therefore  saturated.  At  this  epoch  the  renal  pains  diminished, 
and  I  voided  no  more  gravel  with  the  urine.  Afterwards  the  pains 
ceased  entirely,  the  urine  became  less  loaded,  and  I  recognized  the  potash 

in  excess.  ,         ^  „  ^\     t      -a^a 

I  ceased  to  use  the  carbonate  of  potash,  and  for  some  months  1  voided 
no  concretions.  Being  subsequently  attacked  withthe  same  symptoms 
I  had  recourse  to  the  same  remedy,  and  I  obtained  the  same  good 
effects  I  have  repeated  this  medico-chemical  experiment  eveiy  time  i 
have  felt  the  same  inconvenience,  and  always  with  success,  i wo  years 
have  now  elapsed  since  I  voided  any  concretions,  though  1  no  longer 
make  use  of  the  potash.^ 

The  following  example  from  my  own  practice  is  not  dis- 
similar : 

In  July  1860,  a  stout  middle-aged  gentleman  brought  to  me  eleven 
small  concretions,  varying  from  the  size  of  a  pea  to  that  of  a  large  pin  s 
head.  He  had  voided  these  with  the  urine  a  few  days  previously ;  they 
were  composed  of  uric  acid.  He  stated  that  three  years  bef^^re  he  was 
attacked  with  renal  colic,  which  subsided  on  the  third  day  with  the  dis- 
charge of  a  small  calculus  by  the  urethra.  From  this  period  to  the 
time  of  my  seeing  him,  attacks  of  renal  colic,  terminating  m  the  dis- 

1  Magendie,  De  la  Gravelle,  p.  85. 
21 


322  GRAVEL    AND    CALCULUS. 

charge  of  small  brownish  concretions,  recurred  with  great  regularity  at 
intervals  of  three  or  four  months. 

The  urine  was  found  to  be  acid  and  high-colored;  the  general  health 
was  somewhat  impaired  by  his  periodical  sufferings. 

In  projecting  the  plan  of  treatment,  it  was  considered  that  the  patient 
had  in  all  probability  a  number  of  similar  concretions  still  lodged  in  his 
kidneys.  The  dissolution  of  these  was  the  first  object ;  the  next  was  to 
prevent  their  formation  in  the  future.  Seeing  the  small  size  of  the  con- 
cretions it  was  thought  that  by  keeping  up  a  persistently  alkaline  state 
of  the  urine  for  a  week  or  two,  complete  dissolution  of  them  would  be 
effected.  With  this  view  citrate  of  potash,  in  two-scruple  doses,  dis- 
solved in  half  a  pint  of  water,  was  administered  every  three  hours  for  a 
fortnight.  Afterwards  the  patient  took  a  drachm  of  the  same  salt  in  a 
tumbler  of  water  night  and  morning  for  a  period  of  three  months.  As 
no  recurrence  of  the  renal  pains  took  place,  nor  the  discharge  of  any 
concretions,  the  medicine  was  discontinued ;  but  the  patient  was  in- 
structed to  take  every  night  before  going  to  bed  a  tumbler  and  a  half  of 
water.  This  practice  he  has  continued  up  to  the  present  time  (October, 
1864).     There  has  been  no  return  of  the  symptoms. 

A  considerable  number  of  examples  of  the  successful  treat- 
ment of  vesical  calculi  by  alkaline  solvents  lie  buried  in  the 
forgotten  publications  which  appeared  in  this  countrj^  about 
the  middle  of  the  last  century,  when  the  remedy  of  Miss 
Stephens  made  so  great  a  noise.  Some  fifteen  or  twenty  cases 
were  also  collected  by  Chevallier  and  Petit  at  a  later  epoch, 
when  the  question  was  resuscitated  in  France  about  the  year 
1840. 

Most  of  these  reports  are  vitiated  by  the  absence  of  informa- 
tion as  to  the  nature  of  the  stone  and  the  condition  of  the  urine. 
At  the  former  epoch  (1740),  urinary  calculi  were  all  supposed  to 
be  of  the  same  nature,  and  that  an  unknown  one.  At  the  latter 
epoch  the  chemical  composition  of  urinary  calculi  was,  indeed, 
known,  but  some  of  the  most  important  points  in  their  develop- 
ment were  misunderstood ;  urinary  chemistry  was  still  in  its 
infancy ;  and  the  same  absurd  pretension  of  universal  efficacy 
was  put  forth  on  behalf  of  alkaline  substances  which  swamped 
their  reputation  in  1740. 

One  of  the  best  illustrations  from  the  earlier  records  is  sup- 
plied by  Dr.  James  Jurin,  who  was  himself  the  sufferer. 

He  was  for  many  years  subject  to  red  gravel.  At  Christmas,  1740, 
he  voided  a  small  stone,  after  suffering  four  days  from  nephritic  colic. 
In  January  and  February  following,  he  perceived  unmistakable  symp- 
toms of  stone  in  the  bladder.  These  he  describes  at  great  length,  and 
with  remarkable  clearness. 

In  March,  he  began  to  take  lixivium  of  soap  or  soap-ley  (a  strong 
solution  of  caustic  potash),  in  gradually  increasing  doses,  until  he 
reached  the  amount  of  an  ounce  or  an  ounce  and  a  quarter  daily.     He 


MEDICAL    TUEATMENT.  823 

took  for  a  single  dose  one  or  two  teaspoonfuls  of  the  lixivium  diluted 
with  three-quarters  of  a  pint  of  water.  The  soap-ley  which  he  employed 
was  "one-fifth  part  heavier  than  river  water"  (i.  e.,  its  specific  gravity 
was  1200,  which  is  about  three  times  as  strong  as  the  liq.  potassio  of 
the  London  Pharmacopoeia). 

He  continued  this  treatment  for  five  months.  On  the  10th  of  July 
he  voided  a  small  smooth  stone  of  the  size  of  an  oat,  and  of  a  reddish 
color.  On  the  27th  of  the  same  month  he  voided  a  second  stone.  On 
August  the  6th  he  voided  a  third  stone ;  and  about  the  beginning  of 
September  a  fourth. 

All  his  symptoms  now  disappeared,  and  he  discontinued  the  medicine; 
but  in  December  he  had  a  return  of  the  vesical  symptoms;  he  also 
noticed  that  his  urine  again  furred  the  chamber-pot,  and  that  he  voided 
a  little  red  gravel,  as  he  had  formerly  done.  He  went  back  to  the  soap- 
ley,  and  in  the  course  of  a  week  parted  with  a  small  rough  reddish  stone. 
From  that  time  he  continued  perfectly  easy.  He  still  took  a  couple  of 
teaspoonfuls  of  the  lixivium  each  day,  and  this  he  found  sufficient  to 
keep  the  urine  from  furring  the  utensil.^ 

The  calculi  in  this  case  were  undoubtedly  uric  acid,  as  may 
be  learnt  not  only  from  their  red  color,  but  also  from  an  experi- 
ment which  Dr.  Jurin  made;  he  found  that  they  dissolved  in 
the  alkaline  ley  and  in  lime-water. 

Of  the  cases  collected  in  France,  I  will  only  cite  one.  In 
Chevallier's  essay,  ten  eases  of  the  successful  use  of  the  bicar- 
bonate of  soda  are  recorded.  Dr.  Petit  has  contributed  some 
half  a  dozen  additional  cases  illustrating  the  effects  of  Vichy 
waters  (which  contain  44  grains  of  bicarbonate  of  soda  to  the 
pint). 

M.  de  L ,  fifty-one  years  of  age,  was  sounded  by  Leroy  d'EtiolIes, 

who  found  a  stone  in  the  bladder.  This  he  believed  to  be  not  large,  and 
suitable  for  crushing.  The  patient,  however,  went  to  Vichy,  and  drank 
the  first  day  seven  or  eight  glasses  of  the  waters.  The  next  day  he  took 
fifteen  glasses,  and  the  iirine,  which  was  previously  very  acid,  became 
constantly  and  strongly  alkaline.  In  a  few  days  he  took  twenty-two 
and  twenty-four  glasses.  The  symptoms,  which  were  before  severe,  now 
subsided  more  and  more,  and  after  seventeen  days  of  treatment  he  voided 
a  smooth  uric  acid  concretion  which  bore  evident  traces  of  dissolution. 
From  this  moment  he  continued  wholly  free  from  symptoms,  and  was 
able  to  take  violent  equestrian  exercise  without  the  least  inconvenience.^ 

The  causes  which  led  to  the  discredit  and  final  abandonrnent 
of  the  alkaline  treatment,  in  spite  of  the  large  mass  of  evidence 

1  The  record  of  this  case  is  bound  up  with  Kutty's  Observations  on  Joanna 
Stephens's  Medicine  for  the  Stone.  Lond.  1742.  Another  good  case  is  related 
by  Whytt,  in  his  Essay  on  Lime-water,  Edin.,  1752  ;  and  a  third,  in  which  the 
successful  result  is  vouched  for  liy  a  post-mortem  examination  made  seventeen 
years  afterwards,  is  recorded  in  the  Philosophical  Transactions  for  1745,  bv  Dr. 
Prinole. 

'^  Dr.  Ch.  Petit,  Du  Mode  d' Action  des  Eaux  Minerales  de  Vichy,  p.  272. 


324  GRAVEL    AND    CALCULUS. 

in  its  favor,  are  now  easy  to  understand.  The  most  important 
of  these  was  the  erroneous  claim  to  universal  applicability  set 
up  for  it  by, its  advocates.  My  experiments  prove  unequivocally 
that  it  is  wholly  powerless  in  all  cases  where  the  urine  is  ammo- 
niacal;  also  in  all  cases  of  oxalate  of  lime  calculi,  and  in  every 
variety  of  phosphatic  calculi.  'No  benelit  can  be  derived  from 
it  except  in  cases  of  uric  acid  calculi,  and  in  these,  only  where 
the  urine  has  7iot  become  ammoniacah  The  indiscriminate  use 
of  the  treatment,  therefore,  could  only  result  in  disappointment. 
Further,  the  treatment  was  carried  out  in  a  very  imperfect  man- 
ner. In  the  earlier  period  (1740),  alkaline  substances  were  given 
in  the  form  of  soap,  calcined  egg-shells,  lime-water,  or  solutions 
of  caustic  potash — all  of  them  nauseous  to  the  taste,  apt  to  de- 
range the  stomach,  and  difficult  to  administer  in  sufficient  doses 
to  prove  efficacious.  In  the  later  period  (1840),  Vichy  waters 
were  chiefly  relied  on.  These  contain  soda,  which,  as  we  have 
seen,  is  an  inferior  solvent  to  potash ;  and  the  great  dilution 
of  the  remedy  in  the  Vichy  waters  must  seriously  impair  its 
power. 

My  own  experience  of  the  alkaline  treatment  in  vesical  cal- 
culi was  gathered  before  some  important  points  were  understood, 
which  later  inquiries  have  made  clear  to  me. 

M.y  first  case  was  one  of  uric  acid  calculus,  and  in  every  way  suitable 
for  the  solvent  treatment ;  but  it  was  carried  out  very  imperfectly,  and 
was  not  persevered  in  sufficiently  long  to  effect  complete  dissolution. 
The  patient  was  a  boy,  four  years  of  age,  admitted  into  the  Manchester 
Infirmary,  December  1, 1858.  The  urine  was  acid,  but  did  not  deposit  any 
crystalline  sediment.  He  was  placed  under  the  influence  of  the  tartrate 
of  potash  and  soda  (Rochelle  salt),  in  the  doses,  at  first,  of  twenty  grains, 
and  afterwards  of  thirty  grains,  dissolved  in  from  four  to  six  ounces  of 
water,  every  two  hours.  The  treatment  was  continued  for  six  weeks. 
The  urine  was  thereby  rendered  very  freely  alkaline.  At  the  end  of  this 
period  the  sound  still  disclosed  the  presence  of  a  stone,  and  the  operation 
of  lithotomy  was  accordingly  performed  by  Mr.  Southam,  with  perfect 
success.  Two  calculi  were  exti'acted,  which  together  weighed  only 
twenty-two  grains ;  they  were  composed  of  pure  uric  acid,  and  their  sur- 
faces were  perfectly  smooth,  and  polished  like  river  pebbles,  without  a 
particle  of  phosphatic  incrustation. 

My  present  experience  enables  me  to  point  out  two  errors  in 
the  plan  of  treatment  followed  in  this  case.  In  the  first  place, 
the  quantity  of  fluid  in  which  the  salt  was  dissolved  was  much 
too  large ;  and  in  the  second  place,  the  salt  used  had  too  feeble 
an  alkalizing  power.  Rochelle  salt,  on  account  of  its  large  pro- 
portion of  water  of  crystallization,  has  less  alkalizing  power  by 
more  than  one-third  than  an  equal  weight  of  the  citrate  or 
acetate  of  potash. 


MEDICAL    TREATMENT.  325 

JSTotwithstanding  these  drawbacks,  it  i.s  not  po.ssiblo  Ijut  that 
a  considerable  amount  of  dissolution  had  taken  place.  The 
urine  was  kept  constantly,  though  feebly,  alkaline  for  six  weeks; 
there  was  no  carbonate  of  ammonia  develo[)ed  in  it,  and  no 
trace  of  phosphatic  deposit  on  the  stones.  These  are  conditions 
in  which,  as  my  experiments  prove,  uric  acid  mast  undergo  solu- 
tion. The  two  calculi  wlien  extracted  weighed  only  22  grains; 
and  yet  one  or  both  of  them  must  have  existed  in  the  bladder 
for  a  period  of  three  years,  for  the  symptoms  of  vesical  calculus 
had  been  distinctly  noticed  for  so  long.  It  is  scarcely  conceiv- 
able that  these  stones  had  not  attained,  in  this  length  of  time,  a 
greater  magnitude  than  they  possessed  when  extracted;  and  it 
seems  not  too  much  to  suppose  that  had  the  treatment,  imper- 
fect though  it  was,  been  persevered  in  for  another  week  or  fort- 
night, the  size  of  the  concretions  would  have  been  sufficiently 
reduced  to  permit  their  escape  spontaneously  by  the  urethra. 

My  second  case  was  a  boy,  aged  twelve,  an  inmate  of  the  Manchester 
Children's  Hospital,  under  the  charge  of  Dr.  Borchardt  and  Mr.  Smart, 
who  kindly  permitted  me  to  direct  the  treatment.  The  urine  was  acid ; 
it  contained  a  little  pus,  and  had  an  inordinate  tendency  to  deposit  uric 
acid  crystals. 

On  September  19, 1860,  the  patient  was  directed  to  take  twenty  grains 
of  the  acetate  of  potash  in  two  ounces  of  water  every  three  hours.  This 
treatment  was  continued  for  thirty-four  days ;  the  urine  was  rendered 
thereby  continuously  alkaline.  At  the  end  of  thirty-four  days,  the 
stone,  being  still  found  on  sounding,  was  successfully  extracted  by  Mr. 
Smart. 

The  calculus  weighed  180  grains,  and  its  form  was  a  flattened  oval ;  it 
was  found  to  be  composed  of  alternating  layers  of  uric  acid  and  oxalate 
of  lime ;  and  its  surface  presented  a  most  peculiar  appearance,  which 
furnished  an  interesting  and  irrefragable  proof  of  the  solvent  action  of 
the  alkalized  urine  on  the  uric  acid  layers  of  the  stone. 

The  outermost  layer  consisted  of  uric  acid,  and  over  the  larger  cir- 
cumference of  the  stone  it  had  a  thickness  in  its  deepest  parts  of  about 
a  line  and  a  half;  but  on  the  flattened  surfaces  the  uric  acid  was  dis- 
solved away,  and  the  subjacent  layer  of  oxalate  of  lime  cropped  through 
it  to  a  considerable  extent.  On  one  side  the  exposed  patch  of  oxalate 
was  as  large  as  a  sixpence,  and  presented  the  ordinary  tuberculated 
appearance  and  dark  brown  color  of  a  mulberry  calculus.  On  the 
opposite  side  two  islets  of  oxalate  were  uncovered,  each  about  the  size 
of  a  large  split-pea.  Surrounding  the  exposed  patches  of  oxalate  were 
found  the  remnants  of  a  thinner,  more  superficial,  and  incomplete  layer 
of  oxalate  of  lime.  The  irregular  patches  of  this  latter  layer  occupied 
a  higher  level  than  the  surrounding  surface  of  uric  acid ;  and  here  and 
there  little  elevations  of  uric  acid  could  be  seen  surmounted  with  a 
shield  of  oxalate  of  lime.  These  elevations  were  partially  undermined; 
the  uric  acid  had  been  attacked  by  the  solvent,  and  the  protecting  shield 
of  oxalate  of  lime  was  in  process  of  being  thrown  off"  by  the  gradual 
melting  of  its  support. 


326  GRAVEL    AND    CALCULUS. 

The  general  surface  of  uric  acid  had  a  characteristic  water-worn 
appearance.  There  were  no  minute  mamillations  such  as  usually  stud 
the  surface  of  uric  acid  concretions;  but  the  surface  was  undulating, 
and  the  hollows  and  intervening  ridges  were  perfectly  smooth.  No 
trace  of  phosphatic  deposit  existed  on  any  portion  of  the  stone. 

Complete  solution  of  the  calculus  was  not  possible  in  this  case. 
A  concretion  composed  of  a  uniform  mixture  of  uric  acid  and 
oxalate  of  lime,  was  found  to  be  attacked  with  considerable 
facility,  by  a  solution  of  carbonate  of  potash,  in  the  phial ;  and 
the  present  specimen  shows  that  thin  and  incomplete  layers  of 
oxalate  of  lime  may  be  undermined  and  disintegrated  by  alka- 
lized urine;  but  if  the  stratum  of  oxalate  be  complete,  and 
entirely  invest  the  stone,  it  puts  an  absolute  bar  to  further  sol- 
vent action.  This  was  the  case  in  the  instance  before  us.  The 
p»artially  uncovered  layer  of  oxalate  of  lime  surrounded  the  entire 
stone ;  and  as  soon  as  the  dissolution  of  the  superincumbent 
layer  of  uric  acid  had  been  completed,  no  further  diminution  of 
size  could  have  taken  place. 

The  treatment  was  not  carried  out  in  this  case  as  efficiently 
as  it  might  have  been.  The  dose  of  the  acetate  should  have 
been  nearly  double:  this  would  have  considerably  more  than 
doubled  its  solvent  effect.  The  alkalescence  of  urine  produced 
in  a  boy  of  twelve  by  tv^enty  grains  of  the  acetate  every  three 
hours  is  but  feeble,  and  does  not  approach  the  highest  solvent 
power  capable  of  being  imparted  to  the  urine. 

My  third  case  was  a  boy  of  six,  admitted  under  my  care  into  the  Man- 
chester Infirmary,  on  January  27,  1862.  The  urine  was  acid,  and  sin- 
gularly free  from  pus,  blood,  and  other  organic  elements.  He  was 
placed  under  the  influence  of  citrate  of  potash — at  first,  in  the  dose  of 
twenty  grains  in  six  ounces  of  water  every  two  hours.  This  was  speedily 
raised  to  twenty-five  grains,  and  continued  with  great  regularity  for  two 
months.  At  the  end  of  this  period  the  dose  was  raised  to  thirty  grains, 
given  two-hourly  in  six  ounces  of  water,  and  continued  for  a  month 
longer.  At  the  end  of  the  third  month  the  stone  was  still  felt  on  sound- 
ing. The  patient  was  then  transferred  to  the  care  of  my  colleague, 
Mr.  Southam,  who  successfully  extracted  the  stone  by  the  lateral  opera- 
tion. It  proved  to  be  a  fine  specimen  of  mulberry  calculus,  excessively 
rough  on  the  surface,  and  not  bearing  the  slightest  traces  of  dissolution. 
Not  a  particle  of  phosphate  existed  on  its  surface.  When  sawn  across 
a  nucleus  of  uric  acid  was  displayed.  The  outer  crust  of  oxalate  of 
lime  was  about  a  line  and  a  quarter  thick. 

The  solvent  treatment  was  carried  out  with  undoubted  effi- 
ciency in  this  case,  for  the  space  of  three  months ;  but,  of  course, 
wholly  in  vain,  owing  to  the  impenetrable  layer  of  oxalate  of 
lime  with  which  the  stone  was  invested.  The  only  defects 
wdiich  my  later  experiments  enable  me  to  point  out,  were  the 


MEDICAL    TREATMENT.  '327 

unnecessarily  large  amount  of  liquid  adniinisterod  and  the  un- 
necessarily frequent  repetition  of  the  dose.  If  the  same  dose 
had  been  given  in  half  the  quantity  of  water,  and  repeated 
every  third  hour,  an  e(|ual  effect  on  the  urine  would  have  been 
})ro(luced. 

These  three  observations  permit  a  deduction  -of  great  im- 
portance to  1)6  drawn  from  them,  nvime]y,  that  a  continuously  riJ /,■//- 
line  state  of  the  urine  does  not  determine  any  precipitation  of  the  earthy 
phosphate  on  the  stone,  so  long  as  the  urine  is  free  from  ammoniacal 
decomposition} 

8.  Discrimination  on  the  Cases  in  ivhieh  the  Solvent  Treaiment  is, 
and  is  not,  Applicable.     The  lirst  and  most  general  limitation  is  : 

A.  The  Solvent  Treatment  is  Inapplicable  to  all  Cases  in  'which  the 
Urine  is  Alkaline.  The  loss  of  the  acid  reaction  of  the  urine  in 
calculous  cases,  is  due,  in  the  overwhelming  majority  of  cases, 
to  ammoniacal  decomposition  from  vesical  catarrh.  This  state 
of  the  urine  determines  the  precipitation  of  a  phosphatic  crust 
on  the  surface  of  the  stone,  and  withdraws  it  completely  from 
the  influence  of  alkaline  solvents. 

B.  When  the  urine  is  acid,  the  case  may  be  regarded  as  prima 
facie  suitable  to  the  solvent  treatment;  but  there  are  still  nume- 
rous limitations  which  reduce  the  cases  really  suitable  within  a 
much  narrower  compass. 

[a)  In  the  first  place,  all  those  cases  are  excluded  in  which  it  is 
known  or  strongly  suspected  that  the  stone  is  composed  of  oxalate  of  lime. 
This  is  sometimes  ascertained  from  the  patient  having  pre- 
viously voided  concretions  of  oxalate  of  lime ;  sometimes  the 
character  of  the  urine  yields  indications  of  the  nature  of  the 
stone;  if  it  deposit  on  cooling  an  abundant  sediment  of  octa- 
hedra,  or  dumb-bells,  the  strong  inference  is  that  the  stone  is 
composed  wholly  or  in  part  of  oxalate  of  lime. 

ip)  When  the  examination  of  the  urine  and  the  previous  his- 
tory of  the  patient'give  no  indication  of  the  nature  of  the  stone,  we 
are  left  in  doubt  (supposing  the  urine  to  be  acid)  whether  the 
calculus  is  composed  of  oxalate  of  lime  or  uric  acid,  or  of  alter- 
nating layers  of  these  two  substances.  There  are  no  data  at 
hand  to  form  an  opinion  as  to  the  probabilities  here  involved. 
Different  countries,  and  even  different  districts  of  the  same 
countr}',  show  considerable  diversities  in  the  relative  proportion 
of  uric  acid  and  mulberry  calculi.     Renal   calculi  also  d'iffer 

^  Ten  years  ago  I  was  consulted  by  a  gentleman,  aged  67,  who,  on  sounding, 
"by  myself  and  a  colleague,  was  found  to  be  suffering  from  stone  in  the  bladder. 
The  urine  was  loaded  with  uric  acid  crystals.  He  was  put  on  a  full  course  of  the 
bicarbonate  of  potash  for  a  period  of  nearly  six  months.  The  symptoms  slowly 
subsided;  no  stone  was  voided,  but  the  patient  has  since  remained,  and  is  now 
(January,  1876)  perfectly  free  from  symptoms  of  stone  or  of  any  irritation  about 
the  bladder. 


328  GRAVEL    AND    CALCULUS. 

essentially  in  regard  to  this  point  from  vesical  calculi.  The 
former  are  generally  composed  of  a  single  substance;  and  in 
about -five-sixths  of  the  cases  this  is  uric  acid.  The  latter,  if 
they  have  sojourned  any  considerable  time  in  the  bladder,  are 
frequently  composed  of  two  or  more  substances  arranged  in 
alternate  layers. 

In  cases  of  renal  calculi  the  patient  should  evidently  have  the 
benefit  of  the  doubt.  No  other  treatment  than  that  by  alkaline 
solvents  is  open  to  the  choice  of  the  practitioner;  and  if  the  cal- 
culi should  be  composed  of  oxalate  of  lime,  the  alkaline  treat- 
ment will  not  aggravate,  if  it  do  not  ameliorate,  the  state  of  the 
patient. 

In  cases  of  vesical  calculi  the  question  stands  difi?erently.  The 
solvent  treatment  comes  here  into  competition  with  the  mechan- 
ical methods  of  lithotomy  and  lithotrity,  which  long  experience 
have  stamped  with  success.  It  is  no  longer  a  question  of  the 
mere  possibility  of  removing  a  calculus  by  means  of  solvents, 
but  of  doing  it  with  less  risk  than  by  lithotomy  or  lithotrity. 

Future  experience  can  alone  decide,  whether  it  is  better  in 
cases  of  this  class  (where  the  nature  of  the  stone  is  quite  uncer- 
tain), to  consign  them  at  once  to  the  operating  table,  or  to  give 
a  preliminary  trial  to  the  solvent  treatment.  It  would  appear 
from  the  cases  reported  in  the  preceding  pages,  that  patients 
who  have  undergone  such  a  trial  may  be  afterwards  transferred 
to  the  surgeon  with  undiminished  chances  of  a  successful  opera- 
tion. Probably  the  most  advantageous  course  to  follow,  if  the 
stone  be  a  small  one,  would  be,  to  try  the  solvent  treatment  for 
a  limited  period — for  six  weeks  or  two  months — and,  if  unsuc- 
cessful at  the  end  of  that  time,  to  proceed  without  further  delay 
to  operation. 

(c)  When  the  stone  is  known  to  he  a  large  one,  the  solvent  treat- 
ment should  not  be  attempted.  The  presence  of  a  large  stone 
in  the  bladder  is  itself  a  perpetual  source  of  danger;  and  the 
larger  the  stone,  the  greater  the  probability  that  it  contains  one 
or  more  layers  of  oxalate  of  lime,  which  will  resist  the  solvent. 
The  length  of  time  which  a  stone  above  the  weight  of  an  ounce 
would  require  for  dissolution,  also  detracts  greatly  from  the 
advantages  of  the  solvent  treatment,  as  compared  with  the 
swifter,  though  less  safe  method  of  lithotomy. 

id)  The  cases  of  vesical  calculi  which  are  especially  suitable  for 
the  solvent  treatment,  are  those  in  which  it  is  known  or  strongly  sus- 
pected thai  the  concretion  consists  of  uric  acid,  and  has  not  yet  attained 
any  great  size.  It  not  unfrequently  comes  to  pass  that  an  indi- 
vidual who  has  previously,  at  divers  times,  spontaneously  voided 
small  uric  acid  calculi,  becomes  afterwards  the  subject  of  vesical 
calculus.  If  such  a  case  come  under  treatment  soon  after  the 
first  appearance  of  symptoms  of  stone  in  the  bladder,  it  is  one 


MEDICAL    TREATMEN'J'.  329 

peculiarly  promising:;  for  the  solvent  treatment.  The  stone  is 
sure  to  be  small,  and  it  is  almost  certain  to  be  wholly  composed 
of  uric  acid.  A  dissolution  of  twenty  or  tliirty  grains  would 
reduce  the  stone  sufHcien'tly  to  enable  it  to  traverse  the  urethra. 
A  more  rational,  safe,  and  certain  plan  of  treatment  is  scarcely 
conceivable  in  any  disease. 

(e)  It  is  probable  that  the  solvent  treatment  judiciously  car- 
ried out,  will  prove  a  useful  adjunct  to  lithotrity.  It  is,  however, 
essential  to  its  employment  that  no  vesical  catarrh,  with  amnio- 
niacal  decomposition  of  the  urine,  ensue  after  the  operation.  If 
the  urine  maintain  its  acidity  after  the  stone  is  crushed,  and  if 
the  fragments  discharged  prove  to  be  uric  acid,  then  the  solvent 
treatment  might  be  expected  to  act  advantageously  by  obviating 
the  inconvenience  and  danger  of  repeated  sittings. 

To  sum  up  in  the  affirmative  :  the  solvent  treatment  is  only 
applicable  in  those  cases  of  vesical  calculi  in  which  the  urine  is 
acid;  the  stone  not  large;  its  composition  known  to  be  uric  acid  or 
strongly  suspected  to  Ije  such. 

9.  Bides  for  Carrying  Old  the  Solvent  Treatment.  The  action  of 
alkalized  urine  is  essentially  slow;  quick  solution,  by  any  man- 
ner of  applying  it,  is  impossible.  To  make  up  for  this  defect, 
its  operation  must  be  continuous  and  incessant.  To  rest  con- 
tent with  alkalizing  the  urine  for  a  few  hours  each  da}-,  is  not 
only  to  reduce  the  solvent  effect  to  an  insignificant  quantity,  but, 
sometimes  at  least,  to  nullify  it  altogether.  I  have  known  urine 
kept  continuously  alkaline  by  acetate  of  potash  for  many  suc- 
cessive days,  recover  its  acidity  and  deposit  uric  acid  within  a 
few  hours  of  the  latest  dose.  It  is  also  of  great  importance  not 
only  to  keep  the  urine  continuouslj^  alkaline,  but  to  keep  it  alka- 
line to  a  certain  degree.  The  experiments  described  at  p.  318 
prove  that  solutions  with  an  alkalescence  below"  three  grains  of 
carbonate  of  potash  to  the  pint,  have  scarcely  a  greater  effect  on 
uric  acid  calculi  than  simple  water.  A  feebly  alkalized  urine 
acts  so  slowl}^  that  (in  cases  of  vesical  calculi)  the  delay  incurred 
counterbalances  the  safety  of  the  treatment  as  compared  with 
mechanical  means,  and  robs  it  of  the  preference  which  it  might 
otherv^nse  deserve. 

To  secure  a  continuous  alkalescence,  the  dose  should  be  re- 
peated at  intervals  of  not  less  than  three  hours,  and  it  should 
be  given  with  rigorous  regularity  during  the  waking  hours.  A 
dose  should  be  taken  the  last  thing  before  retiring  to  rest,  and 
another  in  the  course  of  the  night.  Of  course,  a  patient  should 
not  be  disturbed  from  sleep  in  order  to  take  a  dose  of  medicine; 
but  patients  wath  vesical  calculi,  scarcely  ever  are  able  to  pass 
the  night,  without  awaking  spontaneously  once  or  more  to 
empty  the  bladder. 

The  best  salts  for  administration  are  the  acetate  and  citrate  of 


330  GRAVEL    AND    CALCULUS. 

potash.  Of  the  former,  the  dose  for  an  adult  should  be  from 
40  to  60  grains  dissolved  in  3  or  4  ounces  of  water;  for  children, 
the  dose  sho.uld  range  from  20  to  30  grains.  The  citrate  (anhy- 
drous) has  nearly  the  same  alkalizing  power  as  the  acetate.  The 
citrate  of  potash  of  the  shops  is  of  uncertain  strength,  and  often 
exceedingly  impure.  The  best  plan  is  to  prepare  the  solution 
directly  from  the  crystallized  bicarbonate  of  potash  and  crystal- 
lized citric  acid.  The  bicarbonate,  when  saturated  with  citric 
acid,  forms  almost  exactly  its  own  weight  of  anhj^drous  citrate ; 
so  that  when  40  grains  of  bicai'bonate  of  potash  are  saturated 
with  the  proper  quantity  of  citric  acid,  there  result  40  grains  of 
citrate  of  potash. 

The  following  prescription  yields  a  solution  containing  one 
drachm  of  the  citrate  in  each  fluid-ounce: 

R. — Potass,  bicarb. .         .     gxij. 

Acid,  citric.     ........     gviij.  gr.  xxiv. 

Aquae       .         .         .         .         .         .         .         .         .     ad  ,^xij. 

The  dose  of  such  a  solution  for  an  adult,  is  6  or  8  fluid- 
drachms  mixed  with  3  or  4  ounces  of  water;  and  for  children, 
3  to  6  fluid-drachms  diluted  in  the  same  proportion. 

In  conducting  the  treatment,  it  is  essential  that  the  freshly 
voided  urine  should  be  frequently  examined.  If  at  any  time  it 
shows  signs  of  ammoniacal  decomposition  the  treatment  should 
be  suspended.  The  advent  of  this  state  is  indicated  by  the 
offensive  ammoniacal  smell  of  the  urine  and  the  increase  of  pus 
and  flaky  matter  in  it.  As  long  as  the  urine  continues  sweet 
when  voided,  no  fear  need  be  entertained  of  the  deposition  of  the 
mixed  phosphates  on  the  surface  of  the  stone. 

10,  The  objections  urged  against  the  alkaline  treatment  have 
been  chiefly  three  : 

(a)  It  has  been  alleged,  that  by  rendering  the  urine  alkaline, 
there  is  danger  of  the  precipitation  of  the  phosphates  on  the  sur- 
face of  the  stone.  The  facts  advanced  in  the  preceding  pages 
dispose  of  this  objection  completely.  If  there  be  ammoniacal 
decomposition  of  the  urine,  the  phosphates  are  deposited  whether 
alkaline  medicines  be  given  or  not,  and  the  concretion  goes  on 
increasing;  but  if  the  urine  be  alkaline  solely  from  fixed  alkali, 
not  a  particle  of  phosphatic  deposit  takes  place. ^ 

(h)  It  has  been  said  that  the  natural  reaction  of  the  urine  is 
acid ;  and  therefore,  that  to  render  it  alkaline  is  to  introduce  an 
unnatural  state,  which  cannot  fail  to  act  deleteriously  on  the 

1  A  want  of  knowledge  of  the  essential  difference  between  urine  alkaline  from 
fixed  alkali  and  urine  alkaline  from  carbonate  of  ammonia,  runs,  like  a  thread  of 
error,  through  the  elaborate  argument  of  Civiale,  in  his  chapter  on  the  "  Disso- 
lution of  the  Stone."  See  chap.  iv.  of  his  work,  Du  Traitement  Medical  de  la 
Pierre. 


MEDICAL    TUKATMKKT .  y/'il 

general  health.  In  a  state  of  lasting  tlie  natural  ui'ine  is  doubt- 
less always  acid;  but  the  researches  of  Dr.  ]ience  Jones,  lully 
confirmed  by  my  own  (see  p.  77),  show  that  the  urine  is  normally 
alkaline  (from  fixed  alkali)  for  several  hours  daily,  after  meals, 
in  many,  if  not  all  healthy  ])ersons.  So  that  the  maintenance 
of  an  alkaline  reaction  of  the  urine  by  fixed  alkali  is  l^y  no 
means  so  unnatural  a  state  as  some  have  supposed. 

(c)  Alkaline  substances,  it  is  urged,  impair  digestion.  This 
objection  was  valid  against  the  ruder  methods  of  alkalizing  the 
urine  formerly  employed.  But  the  acetates  and  citrates  have 
no  such  effect.  The  introduction  of  these  salts  (and  the  bicar- 
bonate) in  recent  times  for  the  treatment  of  articular  rljeuma- 
tism,  has  aflbrded  an  immense  field  for  watching  their  effects. 
Indeed,  the  solvent  treatment  here  recommended  is  identical 
with  the  alkaline  method  of  treating  rheumatism,  except  that 
the  dose  is  administered  in  a  somewhat  more  dilute  form.  In 
the  last  twenty  years  I  have  employed  the  bicarbonate,  the 
acetate,  and  the  citrate  of  potash,  both  in  private  and  jDublic 
practice,  in  doses  of  four,  six,  and  eight  drachms  in  the  twenty- 
four  hours,  in  a  very  large  number  of  cases.  The  majority  were 
cases  of  articular  rheumatism;  the  remainder  embraced  a  variety 
of  slighter  and  more  severe  disorders — skin  diseases,  emphy- 
sema, diabetes,  acute  Bright's  disease,  etc.  The  urine  was  kept 
continuously  alkaline  for  periods  varying  from  a  fortnight  to 
three  months,  and  in  no  instance  were  deleterious  effects  ob- 
served. In  one  patient  with  pulmonary  emphysema,  the  urine 
was  kept  uninterruptedly  alkaline  for  fourteen  weeks,  with 
marked  improvement  of  the  general  health  and  steady  increase 
of  weight.  In  short,  the  acetate  and  citrate  of  potash  have 
appeared  to  me  about  as  harmless  as  so  much  sugar. 

The  evidence  of  the  Rev.  W.  Vernon  Harcourt  on  this  point 
is  worth  quoting.  He  was  for  several  years  the  subject  of  stone 
in  the  bladder;  but,  owing  to  his  great  age,  and  the  slight 
inconvenience  he  suffered,  operative  procedures  were  not  con- 
sidered desirable.  On  the  suggestion  of  Mr.  Spencer  Wells  and 
myself,  he  resolved  to  try  the  alkaline  treatment,  more  with  the 
purpose  of  keeping  the  growth  of  the  stone  in  check,  than  with 
the  hope  of  removing  it  altogether.  Mr.  Harcourt  has  pub- 
lished an  interesting  account  of  his  case,  wdiich  he  made  ,the 
subject  of  a  chemical  study.  I  have  already  quoted  his  im- 
proved method  of  estimating  the  amount  of  uric  acid  in  the 
urine  {see  p.  90).  Speaking  of  the  effect  of  the  alkaline  treat- 
ment on  himself,  he  says  : 

"  My  experience  of  the  effects  of  citrate  of  potash,  not  exceed- 
ing 300  grains  taken  in  24  hours,  and  producing  an  alkalinity 
equalizing  from  20  to  25  grains  of  carbonate  of  po'tash  (per  pint), 
continued  during  three  months,  has  convinced  me  that  no  sen- 


332  GRAVEL    AND    CALCULUS. 

sible  disadvantage  to  health  need  be  feared  from  such  a  course ; 
and  this  is  the  experience  of  a  man  eight}'  years  of  age,  who  has 
been  for  some  years  an  invalid.  ]N^either  during  nor  since  the 
treatment  lias  any  irritation  of  the  bladder  been  felt,  and  the 
urine  has  been  for  many  months  perfectly  clear ;  it  was  never 
ammoniacal  or  albuminous."^ 


On  the  Solcent  Treatment  of  Uric  Aeid  Calculi  hy  Injections 
into  the  Bladder. 

It  has  been  conceived  that  considerable  advantage  would  be 
gained,  in  cases  of  vesical  calculi,  by  injecting  the  solvent  directly 
into  the  bladder,  in  a  continuous  stream,  by  means  of  a  double- 
current  catheter.  The  advantages  chieHy  counted  on  were : 
the  use  of  stronger  solutions,  and  the  employment  of  a  greater 
mass  of  the  solvent.  In  the  case  of  uric  acid  calculi,  numerous 
experiments  undertaken  by  myself  show  clearly  that  these  ad- 
vantages are  illusory. 

The  mode  of  proceeding  which  I  adopted,  was  to  place  a 
section  of  a  uric  acid  stone  in  a  ten-ounce  phial,  and  to  pass 
over  it  at  blood  heat,  a  current  of  the  solvent  as  large  as  the 
capacity  of  the  urethra  might  be  supposed  to  permit.  The 
current  was  kept  up  for  two  or  three  hours  continuously. 

From  experiments  already  recorded  at  p.  318,  the  maximum 
solvent  power  of  the  carbonated  alkalies  is  ascertained  to  lie  in 
solutions  containing  about  50  grains  to  the  pint.  A  solution  of 
carbonate  of  potash  of  this  strength  was  passed  over  a  fragment 
of  uric  acid  weighing  57  grains,  at  the  rate  of  forty-two  pints 
per  hour,  for  a  period  of  three  hours.  The  result  was  a  disso- 
lution at  the  rate  of  two  grains  per  hour.  This  result,  insig- 
nificant as  it  is,  could  probably  not  be  approached  in  the  living 
bladder  on  account  of  the  mechanical  difficulties  to  be  overcome. 

Solutions  of  the  following  substances  were  also  tried  in  a  simi- 
lar manner,  namely,  borax,  borax  with  liquor  sodce,  double  borate  of 
potash  and  soda,  common  phosphate  of  soda,  basic  phosphate  of  soda, 
and  potash  soap  ;  but  their  solvent  effects  did  not  reach  beyond 
a  loss  of  weight  of  one  or  two  grains  in  the  hour. 

Lime-water  in  a  continuous  current,  at  the  rate  of  30  pints  per 
hour,  dissolved  a  fragment  weighing  86  grains,  at  the  speed  of 
one  and  a  half  grain  per  hour. 

Seeing  the  very  small  results  thus  obtained,  I  proceeded  to 
try  the  caustic  alkalies,  which  are  the  most  powerful  known  sol- 
vents of  uric  acid.  But  solutions,  such  as  could  be  borne  by 
the  living  bladder,  of  liquor  potassse  and  liquor  sodse  (60  and 

1  Med.  Times  and  Gaz.,  1869,  ii.  484. 


MEDICAL    TREATMENT.  383 

120  minims  to  the  pint),  did  not  disHolve  more  than  al^oiit  two 
grains  per  hour. 

The  general  conclusion  from  these  ex})eriments'  is,  tljat  under 
the  most  favorable  conditions,  and  with  the  most  efi:ecti\'e  sol- 
vents capable  of  being  borne  by  the  living  bladder,  no  greater 
dissolution  than  one  or  two  grains  per  hour  can  be  accomplished 
in  the  case  of  uric  acid  calculi.  In  actual  practice  the  con- 
ditions would  necessarily  be  muclj  less  favoral)le  than  in  an 
experiment  performed  in  the  laboratorj^  A  little  consideration 
is  sufficient  to  show  that  these  residts  hold  out  no  prospect  of 
any  useful  practical  application. 

Solvent  Treatment  of  Cystine  Calculi. — Cystine  is  soluble 
both  in  the  carbonates  of  the  tixed  alkalies  and  in  the  mineral 
acids.  It  may  therefore  be  attacked,  when  existing  as  a  calculus 
in  the  bladder,  either  by  alkalizing  the  urine,  as  in  the  solvent 
treatment  of  uric  acid,  or  by  injecting  acid  solutions  into  the 
bladder. 

Two  experiments  were  performed  with  a  view  of  testing  the 
solubility  of  a  cj^stine  calculus  in  a  solution  of  carbonate  of 
potash  containing  40  grains  to  the  pint.  The  mean  result,  with 
a  daily  flow  of  three  and  six  pints,  showed  a  rate  of  dissolution 
equal  to  20  per  cent,  of  the  weight  of  the  stone  in  twenty-four 
hours. 

I  have  recently  (1883)  had  an  opportunity  of  testing  clinically 
the  solvent  power  of  alkaline  remedies  in  a  case  of  cystine  cal- 
culus. The  results  w^ere  wholly  disappointing.  No  impression 
whatever  was  made  on  the  concretion — although  the  treatment 
was  carried  out  resolutely  for  several  months.  And  I  was  sur- 
prised to  find  that  the  patient's  urine,  even  when  rendered  fully 
alkaline  b}^  the  administration  of  citrate  or  bicarbonate  of  pot- 
ash, still  contained  crystals  of  cystine  floating  in  it.  This  indi- 
cated not  onlj^  that  the  treatment  was  not  exercising  anj-  solvent 
action  on  the  concretion,  but  that  the  conditions  for  its  growth 
and  enlargement  still  persisted  in  spite  of  the  alkaline  reaction 
of  the  urine.  I  attributed  this  failure  to  the  concurrent  presence 
in  the  urine  of  carbonate  of  ammonia.  For  the  carbonate  of 
ammonia,  unlike  the  carbonates  of  potash  and  soda,  does  not 
dissolve  cystine — on  the  contrarj'  it  precipitates  it  from  its  alka- 
line solutions.  The  stone  was  a  very  large  one,  and  it  subse- 
quentl}"  was  removed  by  Sir  Henr}"  Thompson  by  the  suprapubic 
operation — and  the  patient  made  an  excellent  recovery. 

Solvent  Treatment  of  Oxalate  of  Lime  Calculi. — In  the 
case  reported  at  p.  326,  alkalized  urine  flowed  over  the  surface 
of  a  mulberry  calculus  for  three  months  without  producing  the 

^    The  experiments  here  referred  to  are  more  fully  described  in  the  author's 
paper  in  the  Mcdico-Chirur^ical  Transactions  for  1865. 


334  GRAVEL    AND    CALCULUS. 

slio;htest  show  of  solution.  I  also  found  that  a  solution  of  car- 
bonate,  of  potash,  containing  40  grains  to  the  pint,  passed  over 
a  mulberry  .calculus  at  the  rate  of  six  and  eight  pints  in  the 
twenty-four  hours,  had  not  the  slightest  solvent  eiiect. 

Better  results,  it  was  conceived,  might  be  obtained  by  a  solu- 
tion of  dilute  nitric  acid  (which  is  the  best  solvent  of  oxalate  of 
lime),  employed  so  as  to  imitate  injections  into  the  bladder.  A 
solution,  containing  120  minims  of  the  concentrated  acid  to  the 
pint,  was  passed  over  a  mulberry  calculus  weighing  53  grains, 
at  the  rate  of  24  pints  per  hour;  and  yet  only  half  a  grain  was 
dissolved  in  an  hour.  We  may  conclude,  from  these  experi- 
ments, that  oxalate  of  lime  calculi  are  unassailable  by  solvents 
applied  in  any  known  method. 

Solvent  Treatment  of  Phosphatic  Calculi. — Phosphatic 
calculi  were  found  quite  unimpressible,  as  might  have  been 
expected,  to  solutions  of  carbonate  of  potash.  Far  more  promis- 
ing results  were  obtained  by  dilute  nitric  acid,  used  so  as  to 
imitate  injections  into  the  bladder.  A  solution  containing  60 
minims  of  the  commercial  acid  to  the  pint,  was  passed  at  blood- 
heat  over  a  phosphatic  stone  weighing  153  grains,  at  the  rate  of 
36  pints  per  hour.  The  loss  of  weight  which  followed  amounted 
to  21  grains  per  hour.  A  modification  of  this  proceeding  was 
successfully  employed,  as  is  well  known,  by  Sir  B.  Brodie,  in 
actual  practice.  My  colleague,  Mr.  Southam,  has  also  tried  the 
same  method,  and  with  the  best  results.  A  stone  had  been 
repeatedly  crushed  with  the  lithotrite ;  but  fresh  phosphatic 
concretions  formed  in  the  bladder  as  fast  as  the  old  ones  were 
broken  up  ;  and  it  was  found  impossible  completely  to  clear  the 
bladder.  In  this  difficulty  an  injection,  containing  two  drachms 
of  dilute  nitric  acid  to  a  pint  of  water,  was  practised  every  day 
or  every  second  day.  In  the  course  of  a  short  time  the  old 
fragments  were  completely  dissolved,  and  the  formation  of  new 
ones  prevented.  This  method  is  evidently  capable  of  wider 
application  than  is  now  made  of  it  by  surgeons. 


CHAPTEK   lY. 

CHYLOUS  URINE. 

The  disorder  named  b}'  Prout  cliylous  urine,  is  rnain]y  a  dis- 
ease of  tropical  climates.  It  prevails  endemically  in  the  Mauri- 
tius, Isle  of  Bourbon,  West  Indies,  the  Brazils,  and  India.  The 
majority  of  the  cases  met  with  among  Europeans  are  found 
among  sailors,  merchants,  colonists,  and  others  who  have  passed 
a  portion  of  their  lives  in  one  of  the  above-named  countries. 

In  this  disorder  the  urine  is  usually  white  and  opaque,  like 
milk ;  sometimes  it  has  a  faint  rose  tint,  from  a  slight  admixture 
of  blood;  and  sometimes  it  is  mixed  with  blood  in  clots. 

On  standing  awhile,  it  sets  spontaneously  into  a  trembling 
coagulum,  which  after  a  time  redissolves,  and  breaks  up  into 
flaky  clots.  l^ot  unfrequently  this  coagulation  takes  place 
within  the  bladder,  and  occasions  serious  pain  and  difficulty  in 
micturition.  The  milky  appearance  of  chylous  urine  is  due  to 
the  presence  of  a  finely  divided  fatty  or  oily  matter.  This  is 
thrown  up  as  a  creamy  layer  after  the  urine  has  stood  some 
hours.  When  chylous  urine  is  agitated  with  ether,  the  fat  is 
dissolved,  and  the  secretion  assumes  the  transparency  and  color 
of  healthy  urine.  The  ethereal  extract  yields,  on  evaporation,  a 
quantity  of  yellowish,  solid  or  oily  uncrystallizable  fat,  resembl- 
ing that  which  is  found  in  the  blood.  Chylous  urine  is  invari- 
ably coagulated  by  heat  and  nitric  acid.  These  united  reactions 
indicate  the  presence  of  tibrine,  fat,  and  albumen.  Caseine, 
though  specially  looked  for  by  many  observers,  has  never  been 
authentically  found  in  chylous  urine ;  nor  is  sugar  usually  found 
therein.^  The  ordinary  ingredients  of  healthy  urine  are  present 
in  their  usual  proportion,  unless  there  is  some  superadded  dis- 
ease. The  specific  gravity  is  generally  below  the  averas^e. 
When  examined  microscopically,  ch3dous  urine  is  found  to 
contain  a  variable  number  of  granular  nucleated  corpuscles,  like 
those  of  mucus  or  chyle;  and  generally,  but  not  always,  red 
blood  disks.  The  fatty  matter  almost  invariably  occurs  in  the 
form  of  excessively  minute  granules  (resembling  the  molecular 
base  of  the  chyle),  which  are  not  resolvable  into  visible  globules 

'  Dr.  Habershon  observes  glj-cosuria  and  polyuria  in  connection  with  chyluria. 
In  this  case  the  sugar  persisted  after  the  fatty  matters  had  disappeared  from  the 
urine.  Yet  it  was  not  merely  a  case  of  the  fatty  urine  which  is  occasionally  ob- 
served in  diabetes,  for  the  urine  coagulated  spontaneously  [see  Lancet,  1.S80,'  i.  p.  ■ 
171).  Mr.  Morison  also  has  desciibed  a  case  in  which  sugar  was  present,  and 
where  the  fat  could  be  obtained  in  crvstalline  form.  (Path.  Trans.,  vol.  x\ix 
p.  394.) 


336 


CHYLOUS    URINE. 


under  the  highest  powers  of  the  microscope.  Occasionally, 
however,  visible  fat  globules  are  found,  as  in  the  case  recorded 
by  Dr.  Waters.  Casts  of  the  uriaiferous  tubes  have  never  been 
found,  though  specially  searched  for  by  Bence  Jones,  Waters, 
Isaacs,  Begbie,  and  myself. 

Sometimes  the  urine  is  not  chylous,  but  lymphous:  that  is,  it 
contains  albumen,  and  coagulates  spontaneousl}^,  but  the  fat  is 
absent,  together  with  the  opaque  milky  appearance  which  de- 
pends thereon.  The  coagulum  in  lymphous  urine  resembles 
calf's-foot  or  currant  jelly. ^ 

In  this  curious  disorder  the  urine  resembles  in  every  par- 
ticular a  mixture  of  ordinary  urine  with  variable  quantities  of 
chjde  or  lymph:  and  a  strong  probability  exists,  as  will  be 
presently  seen,  that  chylous  and  lymphous  urines  are,  in  fact, 
such  mixtures. 

The  unnatural  ingredients — albumen,  fat,  and  tibrine — vary 
considerably  in  their  relative  proportions.  The  following  table 
presents  an  abstract  of  nine  analyses  of  chylous  urine  by  differ- 
ent authors : 


^ 

^,_^ 

,_^ 

^ 

„ 

IM 

g  s 

=;; 

Mi 

So  '^' 

^^ 

o      ----- 

M<1 

p'si 

^^- 

<     . 

p^ 

<] 

p^a 

S 

■"■"-' 

Fatty  matter 

1.90 

1.10 

1.30 

139 

0.79 

0.99 

0.20 

Albumen        .... 

0.70 

0.33 

0.20 

1.30 

1.40 

0.60 

0.17 

Normal  solids  of   the  urine. 

2.30 

4.71 

3.73 

2.57 

2  88 

1.68 

3.04 

Water   ..... 

95.10 

93.86 

94.77 

94.74 

94.93 

96.73 

96.59 

100.00 

100.00 

100.00 

100  00 

100.00 

100.00  100.00 

1  Mr.  Stocks,  of  Salford,  sent  to 'me,  November  18,  1864,  a  man  named  Wil- 
liams, aged  twenty-seven,  who  had  never  resided  out  of  England.  In  1862  this 
man  was  the  subject  of  lymphous  urine  for  about  a  month.  He  was  at  that  time 
sulfering  from  an  extensively  distributed,  and  severe,  cutaneous  disease  of  an 
eczematous  character.  Mr.  Stocks  gives  the  following  description  of  the  urinary 
symptoms.  'There  was  great  pain  over  the  kidnej's,  in  the  perineum,  and  about 
the  anus — defecation  aggravating  the  latter  much.  No  tenderness  existed  in  the 
prostate.  There  was  stillicidium  urinse,  and  frequent,  painful,  straining  micturi- 
tion— half  an  ounce  of  urine  passing  at  once.  Masses  resembling  pieces  of  tripe, 
about  the  thickness  of  a  lead  pencil,  were  pulled  out  of  the  urethra  two  or  three 
times  a  day  for  about  a  week.  The  urine  itself  was  clear,  highly  albuminous, 
and,  when  allowed  to  stand,  coagulated  spontaneously  into  yellow  transparent 
masses,  floating  in  the  fluid  part  of  the  urine,  exactly  like  half-melted  calf's-foot 
jelly.  These  masses  again  became  fluid  in  about  twenty-four  hours,  leaving  coh- 
webby  fibres  floating  in  the  urine."  When  this  man  was  seen  by  me  he  had  lost 
the  cutaneous  eruption,  and  was  able  to  follow  his  employment  as  warehouseman. 
Micturition  was  still  unduly  frequent ;  but  the  urine  was  free  from  fibrine  and 
albumen.  The  only  unnatural  objects  found  after  a  careful  microscopical  examin- 
ation were  a  few  blood  and  pus  C(n'puscles.  Was  this  case  an  example  of  eczema 
invading  the  mucous  membrane  of  the  bladder? 


CHARACTERS    OF    THE    URINE.  337 

The  course  of  the  disorder  is  marked  l)y  an  irrcgulai-ity  and 
capriciousness  which  bafHc  explanation.  The  invasion  is  sonie- 
tiniCK  gradual;  but  more  commonly  it  breaks  out  suddenly 
without  previous  warning  or  known  cause.  In  other  cases  it 
comes  on  apparently  after  a  fall  or  shock,'  or  in  consequence  of 
hard  mental  or  bodily  work.  In  a  case  seen  by  me  the  disease 
came  on  after  parturition.  Its  further  progress  is  essentially 
intermittent;  but  it  rarely  ha])pens  that  the  intermissions  follow 
any  regular  rule.  An  attack  may  last  a  few  days,  a  few  months, 
or  many  years.  The  intervals  between  the  attacks  vary  simi- 
larly; the  disorder  may  go  on  intermittingly  for  two,  three,  or 
more  years,  then  cease  for  ten  or  more  years,  and  be  again  re- 
newed. The  suspensions  and  renewals  are  generally  quite 
abrupt,  sometimes  more  graduaL  Daring  the  remissions  the 
urine  returns  to  a  perfectly  normal  state.  Sometimes  the 
attacks  observe  a  certain  periodicity.  In  one  case  it  is  related 
that  the  urine  always  became  chylous  for  eight  days  previous  to 
menstruation;  in  another,  the  recurrence  almost  always  preceded 
or  accompanied  attacks  of  epilepsy  or  erysipelas.  In  Mr.  Pearse's 
case  the  urine  became  chylous  when  the  patient  was  suckling 
her  children,  and  ceased  to  be  so  shortly  after  weaning  them.  It 
has  been  observed  in  several  instances  that  an  intercurrent  dis- 
order, such  a  fit  of  the  gout,  hepatitis,  carbuncles,  inflammation 
of  the  lungs,  severe  ptyalism,  has  temporarily  suspended  the 
chylous  condition  of  the  urine.  In  other  instances  it  dates  its 
origin  or  renewal  from  some  such  attack. 

There  are  also  diurnal  irregularities  in  regard  to  meals,  exer- 
cise, and  rest,  which  are  inexplicably  contradictory.  As  a  rule, 
rest  and  fasting  diminish  or  suspend  the  milkiness  of  the  urine. 
In  some  cases  the  urine  is  chylous  throughout  the  twenty-four 
hours :  in  others  it  is  natural  or  lymphous  on  rising  in  the 
morning,  and  chylous  during  the  remainder  of  the  day,  espe- 
cially after  dinner;  in  Mr.  Cubitt's  case  (cited  by  Beale)  the 
urine  was  never  chylous  during  the  day,  but  only  on  rising  in 
the  morning.  In  Ackermann's  case  the  urine  became  perfectly 
natural  wdien  the  patient  lay  on  his  right  side,  and  immediately 
resumed  it  chylous  character  when  he  stood  up.  Dr.  Bence 
Jones  found,  in  a  case  observed  by  him,  that  meals  and  exercise 
had  a  marked  influence  on  the  state  of  the  urine.  Shortly  after 
a  meal  the  urine  became  chylous :  if  a  patient  fasted  and  took 
exercise,  the  urine  was  lymphous:  if  he  fasted  and  remained 
perfectly  tranquil,  it  became  natural.  Dr.  Mackenzie  observed 
in  his  case,  that  alterations  in  the  meal-times  j^roduced  altera- 
tions in  the  characters  of  the  urine.    Thus,  the  day  urine  almost 

1  In  Egger's  case  the  patient  attributed  her  disorder  to  the  mental  and  bodily, 
shock  sustained  in  a  fearful  railway  collision,  six  months  before  the  urine  first  be- 
came chylous. 

22 


338  CHYLOUS    URINE. 

completely  coagulated  and  contained  a  considerable  amount  of 
blood,  while  the  night  urine  did  not  form  so  large  a  coagulum, 
and  contained  less  blood  and  was  much  more  milky.  An 
alteration  of  a  few  hours  in  the  meal-times  caused  the  charac- 
ters of  the  day  and  night  urines  to  approximate,  while  when  the 
habits  of  day  and  night  were  completely  reversed,  the  conditions 
of  the  urine  were  similarly  reversed.  In  Mr.  Dutt's  case  the 
urine  voided  during  the  day  was  clear  and  free  from  chyle, 
while  that  voided  during  the  night  and  in  the  morning  was 
deeply  loaded  with  it. 

ILLUSTEATIYE  CASES. 

The  following  abstracts  of  cases  will  convey  an  idea  of  the 
character  of  the  urine  and  the  capricious  course  of  the  dis- 
orders : 

Case  1. — A  woman,  set.  25,  was  admitted  into  the  Manchester  In- 
firmary in  the  spring  of  1868,  suffering  from  chylous  urine.  She  was 
born  in  this  neighborhood,  and  had  never  lived  out  of  the  county. 
Seven  months  ago  she  was  confined,  and  ever  since  the  urine  had  been 
milky.  Her  general  health  on  admission  was  good.  The  urine  was 
more  or  less  milky  throughout  the  twenty-four  hours— sometimes  it  re- 
sembled thin  skimmed  milk,  and  sometimes  it  had  the  appearance  of 
rich  new  milk.  It  generally  coagulated  spontaneously  on  standing  a 
few  hours  into  a  tremulous  jelly,  resembling  ill-made  blanc-mange.  At 
other  times  no  spontaneous  coagulation  took  place,  the  milky  fluid  main- 
taining its  diffluence  unchanged  for  two  days.  It  did  not  throw  up,  as 
a  rule,  any  creamy  layer  on  standing.  Its  specific  gravity  varied  from 
1012  to  1018.  When  fresh  it  was  quite  odorless.  Under  the  micro- 
scope no  visible  oil  globules  were  seen,  but  myriads  of  minute  molecules. 
In  addition  to  the  molecules  a  number  of  cells  were  seen  exactly  resem- 
bling chyle  corpuscles,  and  a  few  scattered  red  blood-disks.  Crystals  of 
triple  phosphate  appeared  in  a  few  hours.  It  coagulated  freely  both 
with  boiling  and  with  nitric  acid,  but  acetic  acid  produced  not  the 
slightest  change  in  it.  When  the  urine  was  shaken  up  with  an  equal 
volume  of  anhydrous  ether,  the  milky  appearance  was  lost,  but  it  did 
not  become  quite  transparent;  it  changed  to  a  yellowish-brown,  with 
some  degree  of  turbidity,  and  after  a  few  hours  a  moderate  deposit  of 
chyle  corpuscles  subsided.  The  milky  appearance  was  not  removed  by 
filtering  through  paper.  No  casts  of  tubes  could  be  detected  after  a 
long  search.  Various  remedies  were  tried  by  Dr.  Morgan — under  whose 
care  the  patient  was — but  without  success.  The  patient  left  the  Infirmary, 
and  has  been  since  lost  sight  of. 

Case  2. — A  married  woman,  aged  thirty,  had  been  passing  chylous 
urine  about  a  year.  Three  specimens  of  her  urine  were  submitted  to 
Dr.  Prout  for  examination,  namely,  one  voided  in  the  morning ;  another 
a  little  after  the  breakfast ;  and  a  third  in  the  evening. 

The  first  specimen,  voided  in  the  morning,  consisted  of  a  solid  jelly- 
like mass  or  coagulum  of  a  pale  amber  color.     This  coagulum  was  of  an 


ILLUSTRATIVE    CASES.  339 

extremely  delicate  texture,  and,  on  being  submitted  to  a  gentle  pres- 
sure or  even  allowed  to  drain,  parted  with  a  large  proportion  of  a  serous 
fluid  of  the  color  above  mentioned,  and  at  the  same  time  became  ex- 
ceedingly reduced  in  bulk,  and  assumed  the  appearance  of  a  red  fleshy- 
looking  mass  of  a  fibrous  texture,  which  on  examination  was  found  to 
have  all  the  properties  of  the  fibrine  of  the  blood,  mixed  with  a  few  red 
particles  of  the  same  fluid.  The  specific  gravity  of  the  serous  portion 
was  1019.  Its  smell  was  very  faintly  urinous ;  reaction  neutral  •  con- 
tained a  large  quantity  of  albumen. 

The  second  specimen,  voided  after  breakfast,  resembled  the  first  in  its 
general  character,  but  differed  from  it  in  some  minor  particulars  Thus 
the  serum  was  more  of  a  whey  color;  the  fibrous  coagulum  was  less  but 
more  compact  and  firm,  and  held  entangled  in  its  texture  a  large'pro- 
portion  of  the  red  particles  of  the  blood.  The  specific  gravity  of  the 
serum  was  only  1012,  and  it  contained  a  considerable  proportion  of 
albumen.  ^ 

The  third  specimen,  voided  in  the  evening,  after  an  early  dinner  taken 
about  noon,  so  closely  resembled  chyle  in  all  respects,  that  Dr.  P.  was 
doubtful,  if  it  had  been  brought  to  him  as  a  specimen  of  that  fluid 
whether  he  should  have  discovered  the  imposition.  It  consisted  of  a 
solid  coagulum  of  a  white  color,  and  assuming  the  shape  of  the  vessel 
like  bianc-mange.  On  being  submitted  to  a  gentle  pressure  and  per- 
mitted^  to  drain,  the  residual  solid  portion  was,  like  that  of  the  others 
small  in  quantity,  but  whiter  than  the  coagula  of  the  other  specimens' 
It  was,  however,  intermixed  with  strings  of  a  firmer  consistence  and  of 
a  red  color.  The  serous  portion  was  white  and  opaque  like  milk  and 
on  being  heated  and  allowed  to  stand  at  rest  for  some  time,  threw  up  a 
substance  on  its  surface  resembling  cream,  and  which,  like  cream  con- 
tained a  considerable  proportion  of  oily  principle.  Its  specific  gravity 
was  1017,  and  its  smell  was  not  urinous  until  it  had  been  concentrated 
by  evaporation ;  it  was  not  coagulable  by  heat,  though  it  contained 
abundance  of  albumen. 

Dr.  Prout  had  an  opportunity  of  examining  this  woman's  urine  after 
fasting  twenty-four  hours.  The  coagulum  was  now  much  smaller  in 
bulk,  and  seemed  to  contain  more  red  particles.  The  serous  portion 
was  nearly  transparent,  and  possessed  in  a  considerable  degree  the  color 
and  other  sensible  properties  of  urine.  It  contained  albumen  and 
abundance  of  urea. 

This  woman  died  emaciated,  after  suffering  from  the  disease  twentv 
years.     (Prout  on  "  Stomach  and  Eenal  Diseases,"  5th  ed.,  p.  117.) 

Case  3.— The  patient  was  a  sailor,  a  native  of  Bermuda,  treated  by 
Dr.  Waters  in  the  Liverpool  Northern  Hospital.  The  characters  of  the 
urine  are  thus  described.  When  first  passed,  it  is  white,  with  rather  a 
pink  tinge.  It  resembles  new  milk  in  appearance  and  somewhat  in 
smell.  It  is  perfectly  free  from  urinous  odor.  After  it  has  been  passed 
for  a  short  time  it  coagulates  into  a  tremulous  mass  exactly  resembling 
blanc-mange.  The  coagulum  sooner  or  later  disappears,  entirely  or  in 
part,  leaving  the  urine  altogether  fluid  or  partly  clotted.  After  the 
urine  has  been  standing  some  hours,  a  distinct  deposit  of  florid  blood  is 
found  at  the  bottom  of  the  vessel,  and  the  mass  of  fluid  above  assumes 


340  CHYLOUS    URINE. 

a  perfectly  white  color,  showing  that  the  pink  appearance  of  the  urine 
when  first  passed  was  due  to  the  admixture  of  blood.  There  is,  in 
addition  to  the  blood-deposit,  a  deposit  of  a  somewhat  slimy  character, 
having  all  the  appearance  of  a  mixture  of  pus  and  mucus.  After  stand- 
ing some  hours,  a  distinct  thin  layer  of  white  fluid,  exactly  resembling 
cream,  generally  forms  on  the  surface  of  the  urine,  the  layer  being 
thicker  in  some  specimens  than  in  others.  The  urine  remains  free  from 
odor  for  some  time,  but  at  the  end  of  three  or  four  days  it  has  a  slightly 
urinous  smell. 

When  first  passed  the  urine  is  slightly  acid  or  neutral,  and  soon 
becomes  alkaline.  Heat  causes  a  precipitate  of  very  fine  particles. 
Nitric  acid  also  produces  a  slight  pi-ecipitate,  but  heat  and  nitric  acid 
together  cause  a  copious  deposit.  When  boiled  with  liquor  potassse  and 
sulphate  of  copper,  there  is  no  reduction  of  the  copper  to  the  state  of 
suboxide.  If  the  urine  be  agitated  in  a  test-tube  with  an  equal  part  of 
sulphuric  ether  and  left  to  stand,  a  thin  layer  of  fatty  (?)  matter  is  de- 
posited on  the  surface  of  the  urine  and  below  the  ether.  The  urine  then 
becomes  quite  clear,  and  if  removed  by  means  of  a  siphon  and  boiled 
with  nitric  acid,  a  copious  deposit  takes  place. 

When  examined  under  the  microscope  the  urine  is  found  to  contain 
blood,  pus,  and  mucous  corpuscles,  with  a  large  number  of  small  fat 
globules.  Many  of  these  last  are  very  minute,  while  others  are  larger. 
No  casts  of  the  uriniferous  tubes  nor  any  other  abnormal  matters  than 
those  already  mentioned,  were  found  in  the  deposit.  The  thin  layer 
of  cream-like  fluid  before  alluded  to  consists  entirely  of  oil  globules. 
(Dr.  Waters,  "  Med.-Chir.  Trans.,"  vol.  xiv.  p.  211.) 

Contrasting  with  this  description  in  the  occasional  absence 
of  spontaneous  coagulation  and  of  visible  fat  globules,  is  the 
follow^ing  account  by  Dr.  Beale  : 

Case  4. — The  specimen  of  urine  was  passed  in  the  morning.  It  was 
perfectly  fluid,  without  any  tendency  to  spontaneous  coagulation,  and 
had  all  the  appearance  of  fresh  milk.  It  had  neither  a  urinous  smell 
nor  taste.  Upon  the  addition  of  an  equal  volume  of  ether,  it  became 
pefectly  clear. 

Under  the  microscope  the  slight  deposit  which  formed  after  standing 
some  time,  was  found  to  consist  of  a  small  quantity  of  vesical  epithelium, 
and  some  small  slightly  granular  circular  cells  resembling  chyle  or  lymph 
ci)rpuscles.  No  oil  globules  could  be  detected  on  the  surface  of  the  urine 
or  amongst  the  deposit,  and  the  fatty  matter,  which  was  equally  diffused 
throughout,  was  in  a  molecular  or  granular  form.  By  examining  the 
urine  with  the  highest  powers  only  very  minute  granules  could  be  de- 
tected. These  exhibited  molecular  movements.  In  this  case  the  urine 
was  not,  however,  always  uncoagulable,  occasionally  it  coagulated  even 
within  the  bladder.  This  case  is  exceptional  in  the  circumstance  that 
the  urine  was  never  chylous,  except  on  rising  in  the  morning.  During 
the  rest  of  the  day  it  was  always  perfectly  natural.  The  patient  was  a 
native  of  Norfolk,  and  does  not  appear  ever  to  have  been  out  of  England. 
(Beale,  "  Urine  and  Urinary  Deposits,"  3d  ed.,  p.  300.) 

Case  5. — A  clergyman,  aged  forty,  born  in  Bermuda,  consulted  Dr. 
Bence  Jones  in  1852.     Ten  years  before  the  urine  became  milky,  and 


ILLUSTRATIVE    GASES.  341 

continued  so  for  eight  weeks;  it  then  returned  to  its  natural  state  with- 
out treatment.  Five  years  after  the  complaint  returned.  The  patient 
passed  clots  and  semi-solid  masses  with  some  difficulty.  The  second 
attack  lasted  two  or  three  months,  and  tlien  the  urine  hecame  perfectly 
natural,  and  continued  so  for  the  succeeding  four  years.  At  the  end  of 
this  period  the  disease  returned,  and  had  continued  ever  since,  with  the 
exception  of  an  interval  of  three  weeks.  When  the  patient  came  under 
the  care  of  Dr.  B.  Jones,  in  1852,  the  urine  was  milky,  but  it  cleared 
with  ether;  it  contained  much  albumen  and  some  blood-corpuscles,  but 
no  casts  of  tubes;  its  reaction  was  acid,  specific  gravity  102o.  The 
patient  stated  that  bodily  or  mental  exertion  (such  as  preaching  on  Sun- 
day) produced  the  most  intense  milkiness  of  the  urine.  Usually  the 
urine  was  milky  on  going  to  bed  ;  it  was  clear  in  the  morning,  until  an 
hour  after  breakfast;  the  whiteness  then  increased  according  to  the 
degree  of  exercise  taken.  He  dined  at  one,  and  then,  with  rest,  the 
urine  became  clear,  and  continued  so  until  he  took  his  afternoon  walk, 
when  the  whiteness  returned.  He  had  tiied  all  sorts  of  tonics,  buchu,and 
iron,  and  had  taken  gallic  acid  on  this  and  the  previous  occasions  without 
advantage.     (Bence  Jones,  "Med.-Chir.  Trans.,"  vol.  xxxvi.  p.  91. j 

Case  6. — A  lady,  aged  sixty-four,  born  in  India,  where  she  had  re- 
sided for  some  years,  came  under  the  care  of  Dr.  Elliotson.  The  urine 
became  for  the  first  time  milky  nine  years  after  her  return  to  England. 
It  continued  milky,  in  spite  of  various  remedies,  for  about  a  year,  when 
it  suddenly  resumed  its  natural  appearance  on  the  third  morning  after 
she  had  commenced  to  take  a  daily  bath  in  the  sea.  The  urine  then 
remained  clear  for  thirteen  years  (eighteen  months  of  which  were  passed 
in  India).  At  the  end  of  this  period  she  had  a  severe  inflammation  of 
the  lungs,  for  which  she  was  bled,  and  took  calomel.  In  a  month  after 
this  attack  the  urine  again  became  chylous,  and  continued  so  for  two 
years.  At  this  time  she  suffered  from  a  severe  mental  shock,  and  for 
the  space  of  one  month  the  milkiness  of  the  urine  was  suspended  ;  it 
then  returned  with  as  much  intensity  as  ever.  From  this  date  the  urine 
continued  milky  without  one  day's  intermission  for  eleven  years.  The 
milkiness  was  then,  once  more,  suspended  for  six  weeks  in  consequence 
of  a  carbuncle ;  then  it  went  on  again  for  two  years,  when  she  had  a 
second  attack  of  inflammation  of  the  lungs,  which  laid  her  up  for  six 
months.  During  this  illness  the  chylous  state  of  the  urine  was  again 
suspended;  but  has  since  returned,  and  still  continues  (1857).  The 
patient  is  a  very  stout  person,  and  very  nervous.  All  remedies  have 
been  unavailing.  The  disease  has  continued,  with  intermissions,  for 
eight-and-twenty  years.  (Elliotson,  "  Med.  Times  and  Gaz.,"  1857, 
ii.  287.) 

Case  7. — An  English  gentleman,  aged  forty,  a  teacher  of  languages, 
settled  in  Rostock  (Germany),  came  under  the  notice  of  Dr.  Acker- 
mann.  In  his  youth,  this  gentleman  had  travelled  for  two  years  in  the 
Brazils  and  Buenos  Ayres.  While  in  South  America  he  suffered  from 
a  slight  hydrocele,^  which  appeared  on  his  return  to  Europe. 

'  Quer^'^ — Was  not  this  supposed  hydrocele  an  affection  of  the  scrotal  lym- 
phatics, as  in  Carter's  cases,  to  he  presently  described? 


342  CHYLOUS    URINE. 

He  had  been  settled  in  Rostock  for  eleven  years,  and  was  strong  and 
very  healthy.  Midsummer,  1858,  he  took  the  measles,  which  left  behind 
a  slight  bronchial  catarrh.  This  catarrh  lingered  on  till  February, 
1859 ;  when  one  day  he  observed  his  urine  to  be  milky.  A  few  hours 
before  this  occurrence  he  felt  out  of  soi'ts  and  shivered,  but  next  morn- 
ing he  was  well  again.  The  urine,  however,  continued  milky,  and  five 
weeks  after,  leeches  were  applied  to  the  left  loin  on  account  of  a  tender- 
ness which  existed  in  that  region.  During  their  application  the  patient 
lay  on  his  right  side  for  two  hours,  and  immediately  on  rising  he  made 
water,  which,  much  to  his  own  and  his  physician's  astonishment,  was 
perfectly  normal,  clear,  and  of  a  deep  yellow  color.  Nevertheless,  at 
the  next  micturition,  the  urine  was  found  milky  again.  .  A  few  days 
after  the  patient  repeated  the  experiment ;  he  emptied  the  bladder,  and 
lay  for  an  hour  on  his  right  side,  and  again  the  urine  appeared  clear, 
and  contained  only  traces  of  albumen.  Similar  results  were  obtained 
many  times  after  the  same  experiment.  If  perfect  rest  on  the  right  side 
was  broken  even  for  a  few  minutes,  the  urine  was  distinctly  chylous  at 
the  end  of  the  experiment.  A  counter-experiment,  in  which  the  patient 
lay  on  his  left  (instead  of  right)  side,  showed  still  more  distinctly  the 
effect  of  the  posture  on  the  right  side.  On  the  6th  of  May  the  patient 
lay  for  an  hour  on  his  left  side ;  but  the  urine  which  he  made  on  rising 
was  strongly  chylous  and  contained  blood.  At  a  later  period  this 
influence  of  lying  on  one  or  the  other  side  became  less  marked  and  con- 
stant. But  throughout  the  complaint,  rest  in  the  horizontal  position 
had  invariably  the  effect  of  diminishing  the  chylous  condition  of  the 
urine.  The  morning  urine,  after  the  rest  of  sleep,  was  always  the  least 
milky ;  and  that  of  the  evening,  after  the  fatigues  of  the  day,  the  most 
so.  The  general  health  was  only  slightly  affected.  He  was  a  little  less 
capable  of  exertion,  more  easily  fatigued,  very  sensitive  to  cold,  and 
somewhat  depressed  in  mind ;  there  was  also  a  dull  pain  in  the  left 
lumbar  region.  The  exhaustion  appeared  to  increase  as  the  disease 
continued,  but  he  was  not  compelled  to  suspend  his  somewhat  arduous 
occupation  for  more  than  a  day  or  two.  He  noted  that  a  hemorrhoidal 
flux  with  which  he  had  been  previously  affected,  ceased  entirely  from 
the  moment  the  urine  became  milky.  In  July  and  August  the  patient 
spent  a  month  at  the  sea-baths  of  Warnemiinde,  where  he  led  a  very 
quiet  life,  but  did  not  bathe.  Here  the  urine  suddenly  became  clear 
and  normal,  and  continued  so  for  a  fortnight ;  but  before  he  left,  it 
became  as  suddenly,  intensely  milky  again.  At  a  still  later  period  more 
frequent  variations  in  the  chylous  and  non-chylous  condition  of  the 
urine  were  observed  than  in  the  beginning ;  but  no  intermission  as  long 
as  that  noted  at  Warnemiinde  occurred  again.  It  often  happened  that 
amid  a  long  series  of  chylous  emissions  a  normal  one  would  be  suddenly 
interposed,  and  it  was  not  always  possible  to  find  any  cause  for  this 
sudden  change  in  the  circumstances  of  the  patient. 

It  was  observed  that  the  skin  was  markedly  less  disposed  to  sweating 
than  previously,  and  sometimes  there  was  a  disagreeable  dryness  of 
the  cutaneous  surface.  The  urine  was  notably  increased  in  quantity, 
especially  in  the  earlier  periods,  when  it  exceeded  five  pints  in  the 
twenty-four  hours. 


ILLUSTRATIVE    CASE8. 


343 


The  examination  of  the  urine  yielded  the  following  resultH:  It  was 
opaque,  almost  milk-white  with  a  tinge  of  red,  reaction  acid,  with  a  stale 
sweetish  odor.  It  coagulated  spontaneously,  sometimes  after  standing  a 
few  minutes,  sometimes  after  several  hours.  It  never  gelatinized  within 
the  urinary  passages.  It  coagulated  with  heat  and  with  nitric  acid. 
When  it  was  allowed  to  rest  for  eighteen  hours  in  a  glass,  a  thin,  per- 
fectly white  layer  gathered  on  the  top,  and  a  reddish  deposit  sank  to  the 
bottom.  In  the  former  a  vast  quantity  of  fat-molecules  were  found  ;  in 
the  latter,  blood-corpuscles  and  small  dark-red  clumps  of  blood.  Ether 
cleared  the  urine  almost  completely,  and  the  extracted  fat  was  solid  at 
ordinary  temperatures.  When  the  urine  was  boiled,  it  passed  through 
a  filter  perfectly  clear,  and  possessing  all  the  qualities  of  healthy  urine 
— the  fatty  matter  having  been  entirely  retained  on  the  filter  by  the 
coagulated  albumen. 

The  following  table  exhibits  the  proportion  of  fat  and  albumen  at 
diflferent  times  of  the  day. 

Table  exhibiting  the  proportion  of  fat  and  albumen  at  different  times  of  the  day  in 
Ackermann's  ease  of  chylous  urine. 


Oct  15 
"    16 


Hour  of 
micturition 


7  am. 

11  A  M 
11  A.M. 

noon. 

.")  V  M. 
0  I'  M. 
10  p  M. 

7  A  M. 


Antecedent 
condition 


j  Siieciflc 
gravity 


Kilt 
percent 


Albumen 
))er  cent. 


Sleep. 
2  hours'  sitting.  I 

2  hours'   tuition! 
out    of    the 

house. 

3  hours    of   the 

same. 
3    hours    of   the 

same. 
3    hours    of   the 

same 
3    liours'    sitting 
and    half-hour 
reclining 
Sleen. 


1(12-1 
1025 

1011 

1024 
1018 
1010 
KJll 

1021 


Yellowish- 
white. 
White,   ^v•ith 
little  yellow. 


Light  yellow- 
ish white. 

Light  yellow- 
ish-white. 


o.x-i 

0.34 

0  47 
0  26 
O.Oil 
0.24 

0  10 


0.5011 
0.145 

0.426 
0  068 
0.420 
0.2112 

0  647 


Xone 
Fibrinous  flakes. 

A  few  pink 
fibrine  flakes. 

Shreds  of  fibrine. 

Brownish-red 
clumps. 
None. 


Shreds  of  fibrine. 


Various  remedies — among  them  gallic  acid — were  tried  in  this  case 
with  little  or  no  evidence  of  success.     In  the  beginning  of  December, 

1859,  he  left  off  all  medicines,  finding  them  of  no  effect  on  his  urine, 
and  feeling  his  general  health  satisfactory.     Toward  the  end  of  January, 

1860,  he  found  himself  one  evening,  after  a  very  heavy  day,  greatly 
exhausted,  and  chilly,  and  therefore  went  earlier  than  usual  to  bed. 
The  urine  on  this  evening  was  strongly  chylous.  Next  morning,  on  the 
contrary,  the  urine  was  perfectly  normal ;  the  succeeding  emissions  were 
similarly  healthy,  and  from  that  day  forth  the  disorder  did  not  return. 
For  three  years  he  has  continued  to  pass  perfectly  natural  urine.  A 
few  days  after  this  favorable  termination,  the  hemorrhoidal  flux  returned, 
and  has  continued  since  with  its  former  frequency.^  (Ackermann, 
"  Deutsche  Klinik,"  1863,  Nos.  23  and  24. ) 

1  This  case  came  under  the  notice  of  Dr.  Thndichum  in  1864.  The  patient  had 
returned  to  England,  and  the  chylous  state  of  the  urine  had  reappeared,  in  con- 
sequence, as  the  patient  believed,  of  higher  living.  Brit.  Med.  Journ.,  1864, 
p.  611.  Elaborate  observations  on  a  case  of  non-parasitic  chyluria  will  be  found 
in  a  paper  by  Siegmund,  Berlin.  Klin.  Wochenschr.,  1884,  No.  10. 


344  CHYLOUS    URINE. 

The  general  health  of  persons  altectecl  with  chylous  urine 
sufl'ers  in  varying  degrees.  Some  persons  preserve  their  em- 
bonpoint undiminished ;  but  the  larger  number  are  markedly 
emaciated.  The  patients  generally  complain  of  lassitude,  in- 
capacity for  exertion,  pains  in  the  loins  and  the  epigastrium. 
The  unnatural  drain  of  the  nutritive  material  explains  most  of 
these  symptoms.  Sometimes  there  is  an  excessive  appetite; 
more  commonly  the  appetite  is  natural  or  indifferent.  The 
long  series  of  years,  during  which  persons  may  void  chylous 
urine,  without  serious  impairment  of  their  health,  shows  the 
comparative  innocuousness  of  the  complaint.  In  Quevenne's 
case  (cited  by  Rayer)  the  patient,  a  native  of  the  Isle  of  Bour- 
bon, commenced  to  pass  chylous  urine  at  the  age  of  25.  From 
this  period  to  the  age  of  73  she  constantly  passed  chylous  urine. 
At  73  the  urine  became  natural,  and  the  patient  thought  herself 
cured  ;  but  after  about  fourteen  months,  the  urine  became  again 
as  chylous  as  ever,  and  continued  so  until  she  reached  the  age 
of  78,  beyond  which  the  report  does  not  go.  In  Dr.  Elliotson's 
case  the  disease  lasted,  oif  and  on,  for  28  years,  without  seri- 
ously afiecting  the  health.  When  death  has  occurred  in  cases 
of  chjdous  urine,  it  has  been  occasioned  by  some  independent 
malady.  In  Dr.  Priestley's  case  the  kidneys  presented  the  fatty 
form  of  Bright's  disease,  and  the  lungs  were  tuberculous.  At 
his  Gulstonian  Lectures,  in  1831,  Dr.  Prout  exhibited  the  kid- 
neys of  a  girl  of  15  who  had  been  passing  chylous  urine.  She 
was  said  to  have  died  of  inflammation  of  the  bowels;  the  kid- 
neys were  perfectly  healthy.  Dr.  Isaacs  had  an  opportunity  of 
examining  the  body  of  a  sailor,  who  during  life  had  been  in  the 
habit  of  passing  chylous  urine,  and  who  had  died  of  general 
tuberculosis.  The  kidneys  contained  a  few  nodules  of  secondary 
tubercle,  but  w^ere  otherwise  perfectly  healthy. 

Etiology. — Chylous  urine  prevails  mostly  in  youth  and  mid- 
dle age.  Of  30  cases  collected  by  me,  3  were  under  twenty ;  7 
between  twenty  and  thirty;  11  between  thirty  and  forty;  6 
between  forty  and  fifty;  and  3  over  fifty.  The  youngest  exam- 
ple is  mentioned  by  Prout,  in  a. male  infant  of  18  months;  the 
oldest  is  Quevenne's  cases,  in  which  the  patient  reached  the  age 
of  78  years. 

Of  these  30  cases,  19  were  males  and  11  females;  but  it 
appears,  that  in  the  countries  where  the  disorder  is  endemic,  it 
is  more  common  among  women  than  men.  The  greater  fre- 
quency of  it  among  men  in  the  European  cases  is  explained  by 
the  far  greater  number  of  men,  who,  as  sailors,  merchants, 
colonists,  etc.,  pass  a  portion  of  their  lives  in  tropical  climates. 

As  to  the  predisposing  causes  of  the  disease,  the  only  one 
made  out  with  certainty  is  residence  in  certain  tropical  coun- 
tries.    Twenty-four  cases  (out  of  30)  were  persons  who  had  been 


PATHOLOGY.  345 

born,  or  had  passed  a  portion  of  their  lives,  in  the  Mauritius, 
Isle  of  Bourbon,  Brazil,  West  Indies,  or  India.' 

The  best  authenticated  cases  in  ])ersons  who  have  never  been 
out  of  Europe  arc — a  case  related  by  Prout;  Mr.  Gossett's  case, 
cited  by  Bird;  and  Mr.  Cubitt's  case,  cited  by  Beale ;  and  the 
case  recorded  by  myself. 

The  state  of  the  blood  has  been  examined  by  Guibourt,  Bence 
Jones,  and  Ord.  None  of  these  observers  found  a  milky  state 
of  the  blood-serum.  Guibourt  (cited  by  Kayer)  obtained  nearly 
twice  as  much  fat  from  the  blood  of  a  Brazilian  affected  with 
chylous  urine  as  from  healthy  blood.  Bence  Jones,  on  the  con- 
trary, found  in  the  blood  of  a  person  whose  urine  was  milky 
both  before  and  after  the  bleeding,  no  increased  proportion 
of  fat. 

Pathology. — It  has  been  generally  assumed  that  the  fat,  albu- 
men, and  librine  of  chylous  urine  are  derived  from  the  blood, 
and  pass  into  the  urine  through  the  kidneys.  Dr.  Prout  says : 
"  The  proximate  cause  of  this  affection  seems  to  lie  partly  in  the 
assimilating  organs,  and  partly  in  the  kidneys.  The  chyle,  from 
some  derangement  in  the  processes  of  assimilation,  is  not  raised 
to  the  blood  standard,  and  consequently  being  unfit  for  the 
future  purposes  of  the  economy,  is,  agreeably  to  a  law  of  the 
econom}',  ejected  through  the  kidneys;  but  these  organs  instead 
of  disorganizing  it,  or  reducing  it  to  the  crystallized  state,  as 
usual,  permit  it  to  pass  through  them  unchanged." 

But  any  view  which  supposes  that  the  unnatural  ingredients 
of  chylous  urine  are  derived  from  the  blood  circulating  in  the 
kidneys  presents  great  difficulties.  The  rapid  alternation  of 
urine  intensely  chylous  or  lymphous,  with  perfectly  natural 
urine  (sometimes  witnessed  within  intervals  of  an  hour  or  two) 
seems  incompatible  with  such  a  supposition.  It  is  also  incredi- 
ble that  blood,  albumen,  and  fibrine  should  pass  from  the  blood 
into  the  urine  through  the  kidneys  without  being  accompanied 
with  casts  of  the  uriniferous  tubes.  The  absence  of  organic 
disease  in  the  kidneys,  and  of  any  clearly  made-out  derange- 
ment in  the  composition  of  the  blood,  also  militates  against  such 
a  view. 

I  believe  that  the  true  pathology  of  chylous  urine  is  to  be 
sought  for  in  the  lymphatics  of  the  urinary  channels;  and  that 

^  The  endemic  prevalence  of  chylous  urine  in  these  countries  is  thoroughly 
attested.  The  various  speakers  in  the  discussion  at  the  Medical  Society  of  Rio 
Janeiro,  reported  by  Rayer,  allude  to  the  disorder  as  a  common  one  among 
negroes.  Dr.  Prout  states  that  Mr.  Thomas,  a  practitioner  from  Barbadoes, 
informed  him  that  he  had  seen  at  least  a  dozen  well-marked  cases  in  negroes  in 
a  practice  of  ten  years.  Dr.  Carter  also  says  that'  the  more  ordinary  forms  of 
chylous  urine  are  "not  uncommon"  in  Bombay.  Dr.  Bancroft,  of  Brisbane, 
Australia,  writes  me  that  cases  of  chylous  urine  are  not  unfrequent  in  the  colony 
of  Queensland. 


346  CHYLOUS    URINE. 

the  real  analogues  of  the  disease  are  to  be  found  among  those 
curious  cases  of  chylous  and  lymphous  discharges  from  the 
cutaneous  surface,  of  which  a  number  of  examples  have  been 
published  in  late  years. ^  It  would  appear,  in  our  present  state 
of  knowledge,  that  some  of  these  cases  are  due  to  a  parasitic 
cause,  and  others  to  a  structural  change  of  a  non-parasitic  char- 
acter. The  following  remarkable  example  may  be  taken  as  an 
illustration  of  the  non-parasitic  cases : 

W.  Robinson,  admitted  into  the  Manchester  Infirmary,  September  21, 
1868,  pet.  45,  always  a  resident  in  Lancashire,  was  troubled  about  two 
years  before  admission  with  a  succession  of  large  subcutaneous  abscesses 
in  various  parts.  One  of  these  was  situated  on  the  lower  part  of  the 
abdomen  ;  it  was  a  long  time  in  healing,  and  one  night  he  picked  off 
the  scab  which  covered  the  scar ;  and  from  beneath  this  exuded,  during 
the  night  and  the  next  day,  a  large  quantity  of  fluid  resembling  gum- 
water.  After  this,  he  noticed  a  number  of  pale,  transparent  vesicles,  no 
larger  than  pins'  heads,  scattered  in  the  right  iliac  region  over  and 
around  the  site  of  the  old  abscess.  When  he  first  observed  them  they 
were  ten  or  a  dozen  in  number,  but  in  a  few  weeks  they  began  to  spread 
and  multiply,  until  in  a  few  months,  they  dotted  the  surface  of  the  lower 
part  of  the  abdomen,  almost  as  low  as  the  pubes  on  the  one  hand,  and 
as  high  as  the  umbilicus  on  the  other.  Some  of  them,  also,  began  to 
discharge  a  pale  watery  fluid.  By-and-by  the  vesicles  and  the  discharge 
began  to  assume  a  thick,  milky  appearance,  and  gradually  they  assumed 
the  condition  in  which  they  were  found  on  his  admission  into  the 
Infirmary. 

On  admission,  the  lower  part  of  the  abdomen  was  seen  to  be  studded 
with  numerous  vesicles  filled  with  a  milk-white  fluid.  These  were 
arranged  partly  in  irregular  groups  and  in  part  singly.  Some  of  the 
groups  contained  three  or  four,  others  eight  or  twelve,  vesicles,  closely 
aggregated  together.  Some  of  the  vesicles  were  so  small  that  they  were 
only  just  visible  to  the  naked  eye,  others  were  as  large  as  peas,  and 
between  these  extremes  were  others  of  every  intermediate  size.  Most  of 
them  were  hemispherical,  and  some  were  oblong  or  irregular,  as  if  two 
or  more  had  coalesced.  In  the  smaller  ones  the  vesicular  membrane 
appeared  quite  transparent,  without  a  trace  of  organization,  their  opaque- 
white  contents  shining  through  them  like  drops  of  rich  milk ;  but  a  few 
of  the  largest  ones  were  distinctly  marked  by  meandering  lines  of  delicate 
bloodvessels,  giving  them  a  faint  rose-color. 

The  skin  over  the  afiected  area  was  thick  and  soft,  and  of  a  dull  red 
color.  When  pressed  with  the  fingers  it  yielded  an  almost  spongy  im- 
pression, but  it  did  not  pit.  The  integument  was  manifestly  hyper- 
trophied,  and  this  gave  to  the  lower  part  of  the  belly  a  protuberant 
appearance.     This  dull-red  tumid  area  was  somewhat  more  extensive 

1  Med.-Chir.  Trans.,  vol.  xlv.  p.  189.  Several  cases  of  chylous  discharge  from 
the  cutaneous  surface  (but  wfthout  chylous  urine)  have  been  recorded.  See  A.  B. 
Buchanan,  Med.-Chir.  Trans.,  xlvi.  Fetzer,  Archiv.  f.  Physiol.  Heilk.,  vii. 
p.  128.  Carter,  Med.-Chir.  Trans.,  xlv.  Demarquay,  Mem.  de  la  Soc.  de  Chir., 
iii.  p.  139.     Also  Trans,  of  Clin.  Soc,  vol.  ii. 


PATHOLOGY. 


347 


than  the  limits  of  the  vesicles,  and  faded  at  the  circumference  into  the 
healthy  skin  about  an  inch  beyond  the  furthest  vesicle  in  all  direclir)n8. 

The  skin  around  the  larger  vesicles,  and  groups  of  vesicles,  was  raised 
into  soft  nipple-like  elevations,  and  had  a  more  decidedly  spongy  feel 
than  elsewhere.  Blight  pressure  caused  no  pain,  but  the  whole  area  was 
more  or  less  tender  on  deep  pressure. 

In  their  normal  state  the  vesicles  were  closed,  and  the  immense 
majority  remained  throughout  in  this  condition ;  but  some  dozen  or  so 


Fig.  48. 


Case  of  W.  Robinson — appearance  of  tlie  irniiti 


'II  the  abdiiiiieii. 


of  the  largest  vesicles  were  at  one  time  or  other  in  a  ruptured  state,  and 
discharged  immense  quantities  of  a  chylous  or  lymphous  fluid.  The 
cause  of  rupture  appeared  to  be  some  slight  movement  or  violence. 
Sometimes  the  act  of  turning  in  bed  sufficed  to  set  the  discharge  in 
motion.  It  rarely  happened  that  more  than  two  or  three  vesicles  were 
discharging  at  the  same  time.  The  quantity  of  this  discharge,  and  its 
occurrence  and  arrest,  were  most  irregular.  Sometimes  several  pints 
would  be  discharged  in  a  day  and  night,  and  sometimes  only  sufficient 
to  moisten  the  cloths  with  which  the  patient  girded  himself.  The  patient 
was  sometimes  continuously  wet  for  three  or  four  wrecks ;  at  other  times 
the  flow  would  continue  only  a  few  hours  or  a  few  days.  The  intervals 
of  complete  dryness  were  similarly  uncertain,  and  varied  from  a  day  or 
a  few  days  to  two  or  three  weeks. 

The  character  of  the  discharge  also  varied ;  sometimes  it  was  like  thick 
milk,  sometimes  like  skimmed  milk,  and  sometimes  perfectly  pale,  like 


348  CHYLOUS    URINE. 

gum-water.  Whether  white  or  pale,  it  was  always  spontaneously  coagu- 
lable,  and  white  or  yellowish  clots  collected  about  the  seat  of  discharge. 
The  color  of  the  unruptured  vesicles  varied  in  correspondence  with  that 
of  the  discharge,  from  milk-white,  or  opalescence,  to  pale  straw.  The 
degree  of  milkiness  at  any  particular  moment  was  always  the  same  in 
all  the  separate  vesicles,  showing  that  the  cause  of  variation  was  not  a 
local  one  particular  to  any  vesicle,  but  something  affecting  the  eruption 
generally,  and  depending  presumably  on  the  state  of  the  blood. 

The  vesicles  varied  not  only  in  color,  but  also  in  fulness  and  turgidity ; 
and  it  was  noticed  that  the  whiter  they  were  the  more  distended  they 
appeared,  and  that  when  they  were  pale  they  were  also  more  flaccid. 

Two  circumstances  affected,  though  somewhat  irregularly,  the  whiteness 
and  fulness  of  the  vesicles,  namely,  the  general  state  of  the  patient's 
health,  and  the  digestion  and  assimilation  of  food.  On  the  days  when 
the  patient  was  out  of  sorts  or  feverish,  the  vesicles  were  paler  and  more 
flaccid  ;  but  when  the  appetite  and  sleep  returned,  the  vesicles  became 
milky  and  turgid. 

The  effect  of  food  was  found  to  be  tolerably  constant  in  kind,  though 
not  uniform  in  degree.  The  vesicles  were  paler  in  the  morning  before 
breakfast,  after  the  prolonged  fast  of  the  night.  At  this  period  they 
were  often  quite  lymphous.  Soon  after  breakfast  they  began  to  grow 
fuller  and  whiter,  and,  as  a  rule,  the  milkiness  increased  through  the 
day,  attaining  its  maximum  some  seven  or  eight  hours  after  dinner.  Of 
course,  the  appearance  of  the  discharge,  if  there  were  any,  followed  the 
same  rule. 

The  vesicles  seemed  to  be  situated  in  the  substance  of  the  cutis,  and 
their  surface-wall  was  evidently  composed  of  something  besides  epithe- 
lium. In  the  larger  vesicles  their  base  was  raised,  and  consisted  of  soft 
cutaneous  tissue;  and  capillary  vessels  could  be  seen  travelling  over 
their  transparent  summits.  When  a  vesicle  was  gently  pressed  with  the 
tip  of  the  finger,  it  was  immediately  emptied,  its  fluid  contents  escaping 
into  the  deeper  parts.  After  the  pressure  was  withdrawn  the  vesicle 
slowly  filled  again.  There  was  no  direct  communication  between  neigh- 
boring vesicles,  and  when  one  was  ruptured  and  discharging,  the  vesicles 
around  it  still  appeared  full  and  turgid.  It  was  noticed,  however,  that 
when  the  discharge  had  been  very  free  for  some  hours,  all  the  vesicles 
appeared  flaccid.  Even  when  a  whole  cluster  was  compressed,  the  neigh- 
boring vesicles  did  not  appear  more  distended.  The  idea  conveyed  by  the 
study  of  the  effects  of  pressure  on  different  vesicles  and  groups  of  vesi- 
cles was,  that  each  vesicle  communicated  with  a  more  deeply  situated 
reservoir  of  anastomosing  channels.  When  a  vesicle  was  pricked,  the 
flow  from  it  immediately  began,  and  it  continued  at  a  steady  rate  for 
hours  together.  On  one  occasion  the  rate  of  flow  from  a  punctured 
vesicle  was  tested,  and  found  to  be  equivalent  to  eight  ounces  per  hour. 

The  characters  of  the  discharge,  whether  it  was  milky  or  opalescent,  were 
always  essentially  the  same.  After  standing  a  few  minutes  it  set  into  a 
tremulous  jelly.  In  a  few  hours  there  was  a  separation  into  clot  and 
serum.  It  coagulated  with  heat  and  with  nitric  acid,  but  not  with  acetic 
acid.  When  shaken  with  an  equal  bulk  of  ether  the  white  appearance  was 
removed,  and  the  fluid  became  transparent  and  yellowish  like  blood- 
serum.     These  reactions  prove  that  it  contained  fibrin,  albumen,  and  fat. 


PATHOLOGY.  349 

and  that  it  differed  essentially  frf)m  true  milk  in  not  containing  casein. 
Tiie  reaction  was  always  alkaline.  The  varying  da^ree  of  rnilkiness 
was,  of  course,  due  to  the  varying  quantity  of  fatty  matter.  Under  the 
microscope,  myriads  of  minute  fat  molecules  were  seen,  sometimes  mixed 
with  larger  oil  globules ;  in  addition  to  these,  pale  corpuscles,  identical 
in  structure  with  the  white  corpuscles  of  the  blood  or  chyle,  were  always 
present,  but  not  in  large  numbers.  No  other  organic  forms  were  ever 
seen  except  the  transparent  fibrilhc  of  coagulated  fibrin. 

The  fluid  is  thus  seen  to  be  similar  in  character  to  chyle  when  milky, 
and  to  lymph  or  liquor  sanguinis  when  pale.  It  is  also  identical  with 
the  admixture  which  takes  place  in  cases  of  chylous  urine.  A  case  of 
chylous  urine^  happened  to  be  in  the  Infirmary  at  the  very  time  the 
present  case  was  under  observation,  and  neither  chemically  (excepting 
proper  urinary  ingredients)  nor  microscopically  could  any  distinction  be 
made  between  them.  Still  more  significant  of  this  alliance  was  the  fact 
to  be  noted  presently,  that  on  two  separate  days  this  man  did  actually 
pass  chylous  urine. 

The  condition  of  the  urine  was  carefully  noted  during  the  progress  of 
the  case.  It  was  generally  found  to  be  remarkably  scanty  in  quantity 
and  of  high  specific  gravity.  When  the  discharge  from  the  vesicles  was 
abundant,  the  quantity  of  urine  ranged  from  13  to  18  ounces  in  the 
twenty-four  hours.  When  the  eruption  was  dry,  the  urine  was  some- 
what more  abundant,  and  varied  from  18  to  25  ounces — on  one  occasion 
it  reached  34  ounces,  and  on  another  40  ounces,  which  was  the  largest 
flow  chronicled  during  his  long  sojourn  in  the  Infirmary.  The  specific 
gravity  varied  from  1025  to  1032^  it  frequently  deposited  lithates,  but 
did  not  contain  either  albumen  or  sugar.  The  scantiness  of  the  urine 
was  partly  due  to  the  voluntary  abstention  of  the  patient  from  drink. 
He  believed  that  drinking  always  increased  the  flow  of  the  discharge  ; 
and  he  endured  constant  and  severe  thirst  in  order  to  check  this  loss. 

On  December  2d  the  urine  was  voided  milky  on  two  occasions.  It 
presented  all  the  ordinary  characters  of  chylous  urine.  Again,  on 
January  15th,  the  patient  passed  three  ounces  of  chylous  urine,  and  on 
the  following  day  fat  was  found  in  the  urine  with  the  microscope,  though 
not  in  sufficient  quantity  to  produce  a  milkiness  of  the  secretion. 
During  these  two  days  the  eruption  was  dry.  With  these  exceptions 
the  urine  continued  of  normal  composition  throughout,  and  free  from 
albumen. 

The  only  general  symptoms  referable  to  the  disease  on  the  abdomen, 
and  the  discharge,  were  attacks  of  chilliness  and  shivering,  with  a  sense 
of  great  weakness.  These  occurred  repeatedly  when  the  discharge  was 
copious  and  long  continued.  He  also  complained  occasionally  of  aching 
pains  in  the  abdomen  and  of  indifferent  sleep;  but,  as  a  rule,  he  was  in  a 
state  of  fairly  comfortable  health  until  tuberculous  symptoms  broke  out. 

When  the  patient  entered  the  Infirmary  in  September,  he  did  not 
appear  to  be  affected  with  any  disease  except  that  on  the  abdomen.  But 
in  March  of  the  succeeding  year  he  began  to  lose  weight,  and  the  tem- 
perature of  the  body,  which  previously  had  ranged  from  97°  to  98.6°, 
began  to  rise,  and  ranged  from  99°  to  102°.      The  physical  signs  and 

1  The  case  already  reported  at  p.  338. 


350  CHYLOUS    URINE. 

symptoms  of  pulmonary  phthisis  also  made  their  appearance,  and 
steadily  progressed.  His  health  slowly  declined,  until  at  length  he  was 
unable. to  leave  his  bed. 

The  eruption  withered  slowly  as  the  pulmonary  disease  advanced  ;  the 
vesicles  became  persistently  pale  and  flaccid  ;  the  discharge  became 
watery  and  scanty,  and  finally  ceased  some  five  days  befijre  death.  The 
state  of  the  eruption  the  day  before  death  is  thus  described  by  my 
clinical  clerk,  Mr.  Patchett.  "  The  vesicles  have  lost  their  character 
of  vesicles  altogether,  they  seem  converted  into  small  furfuraceous  scales 
of  difierent  colors,  some  being  of  a  reddish-yellow,  others  of  a  raspberry, 
color;  the  small  vesicles  scattered  over  each  flank  look  exactly  like 
flea-bites." 

The  urine  was  reduced  to  six  and  eight  ounces  per  day  in  the  last 
week,  and  the  symptoms  assumed  the  so-called  typhoid  character — with 
low  muttering  delirium,  indiflTerence,  picking  at  the  bedclothes,  and 
finally  coma.     Death  occurred  on  May  22d. 

Autopsy  Twenty-one  Hours  after  Death. — Both  lungs  were  studded 
with  gray  granulations  intermixed  with  larger  masses  of  gray  and  yel- 
low tubercle,  some  of  which  were  softened.  Two  small  vomicae  were 
found  in  the  left  apex,  and  one  in  the  right.  Tuberculous  ulcers  were 
also  found  in  the  small  and  large  intestines.  The  bronchial  and  mesen- 
teric glands  were  enlarged.  The  liver  weighed  sixty-four  ounces,  and 
the  spleen  nine  ounces ;  both  organs  were  healthy.  The  kidneys  and 
bladder  were  healthy.  The  integument  of  the  hypogastrium  was  much 
thickened  and  spongy,  contrasting  strongly  with  the  emaciated  integu- 
ment over  the  thorax.  The  lining  membrane  of  the  bladder  was 
minutely  examined,  and  appeared  smooth,  glistening,  and  healthy 
throughout.  No  enlargement  or  unnatural  condition  of  the  thoracic 
duct  or  of  the  lymphatic  vessels  or  glands  could  be  detected.  A  con- 
siderable piece  of  the  abdominal  wall,  embracing  a  portion  involved  by 
the  disease  and  a  portion  extending  beyond  into  the  healthy  skin,  was 
cut  out  for  further  examination. 

Examination  of  the  Skin  in  the  Diseased  Area. — On  making  a  vertical 
section  through  the  skin  and  subjacent  parts,  it  was  at  once  perceived 
that  the  disease  involved  essentially  the  cutis  vera  and  the  subcutaneous 
tissue.  The  tendinous,  muscular,  and  peritoneal  strata  were  in  every 
respect  perfectly  normal.  The  skin  was  immensely  thickened,  and 
formed,  with  the  subcutaneous  tissue,  to  which  it  was  structurally  united, 
a  thick  pad  or  layer  of  tissue  varying  from  half  an  inch  to  an  inch 
thick.  When  fresh,  the  cut  surface  had  a  pale  rose  and  somewhat  fleshy 
or  granular  appearance.  This  tissue  was  traversed  by  short  channels  or 
lacunae,  varying  from  the  width  of  a  crow-quill  to  that  of  a  hair.  By 
making  numerous  thin  sections  vertically  and  horizontally  and  examin- 
ing them  with  a  lens  and  a  microscope,  these  lacunae  could  be  seen  to 
communicate  freely  with  each  other  by  small  smooth  orifices.  Tha 
vesicles  evidently  constituted  the  surface  boundaries  of  the  more  super- 
ficial lacunae.  The  lining  membrane  of  the  lacunae  and  of  the  vesicles 
was  smooth  and  glistening ;  and,  when  gently  scraped  with  a  knife,  it 
yielded  a  small  quantity  of  a  whitish  debris,  which,  under  the  micro- 
scope, resolved  itself  into  spheroidal  and  nucleated  cells  resembling  those 
which  were  found  in  the  discharge  during  life. 


PATHOLOGY.  361 

Here  are  evidently  the  elements  of  a  glandular  structure — a  mem- 
brane lined  with  spherical  nucleated  cells.  But  the  analogy  is  rather 
with  the  ductless  follicles  of  Peyer's  patches,  and  still  more  with  the 
ganglia  of  the  lymphatic  chains  than  with  the  glands  engaged  in  the 
regular  work  of  secretion  and  possessing  excretory  ducts.  The  new 
structure  had  no  connection  with  the  normal  glands  of  the  skin.  The 
funnel-shaped  orifices  of  the  sweat-glands  could  be  seen  opening  inde- 
pendently on  the  surface  in  the  hollows  between  the  vesicles,  and  the 
hair  follicles  presented  their  normal  appearance. 

The  chief  interest  in  the  case  lay  in  the  light  which  it  throws 
on  the  pathology  of  chylous  urine.  It  can  scarcely  be  doubted 
that  the  case  was  generically  identical  with  that  curious  dis- 
order. The  absolute  similarity  of  the  discharge  with  the  fibro- 
albuminous  and  fatty  elements  added  to  the  urine  in  chylous 
urine,  the  sudden  appearance  and.  cessation  of  the  discharge,  the 
capricious  terms  of  the  duration  of  the  discharge  in  the  two 
disorders,  and  the  actual  occurrence  of  chylous  urine  on  two 
occasions  in  the  case  of  Robinson,  scarcely  leave  any  room  for 
doubt  on  this  point.  Had  the  disease  in  this  case,  instead  of 
occupying  the  subcutaneous  tissue  of  the  abdomen,  been  devel- 
oped in  the  submucous  tissue  of  any  part  of  the  urinarj^  pass- 
ages, it  is  evident  that  the  conditions  for  the  production  of  an 
ordinary  case  of  chylous  urine  would  have  existed.  It  is  even 
almost  certain  that  some  small  part  of  the  urinary  membrane — 
probably  that  of  the  front  of  the  bladder — was  actually  invaded 
by  the  disease  which  afi'ected  the  abdomen,  but  no  anatomical 
traces  of  such  extension  could  be  detected  at  the  autopsy,  owing 
probably  to  the  fact  that  in  the  last  few  weeks  of  life  the  morbid 
process  had  retrograded,  and  had  consequently  left  no  apprecia- 
ble marks  on  the  surface  of  the  bladder. 

It  may  be  assumed  with  some  confidence,  that  in  some  cases 
of  chylous  urine  the  disease  is  essentially  of  the  same  patho- 
logical nature  as  the  disease  on  the  abdomen  of  Robinson.  And 
looking  to  the  absolute  identity  of  the  discharge  in  these  cases 
with  chyle  and  lymph,  it  is  difficult  to  avoid  the  impression  that 
the  structures  which  produce  this  discharge  are  anatomically 
analogous  to  the  lacteal  and  lymphatic  tissues.  The  examina- 
tion of  the  skin  of  the  abdomen  in  Robinson's  case  gave  strong 
support  to  this  view.  When  the  preparation  was  fresh,  the 
thick,  soft  layer,  into  which  the  skin  and  subcutaneous  tissue 
were  converted,  had  very  much  the  pale  flesh-color  and  general 
appearance  of  lymphatic  gland  tissue;  and  the  short  communi- 
cating lacunae  traversing  it  in  all  directions,  suggested  a  struc- 
ture not  dissimilar  to  an  immense  exaggeration  of  the  lymphatic 
plexus,  I  found  it  impossible  to  resist  the  idea  that  this  was 
really  the  true  pathological  solution  of  the  case,  and  that  a 
similar  solution  applied  to  cases  of  ch3'lous  urine. 


352  CHYLOUS    URINE. 

It  is  well  known  that  the  skin  with  the  subcutaneous  tissue, 
and  the  mucous  membranes  with  the  submucous  tissue,  are 
exceedingly  rich  in  Ij^mphatics,  which  form  a  close  network  of 
communicating  channels  in  these  situations.  It  is  further 
known  that  the  cells  lining  the  Ij^mphatic  channels,  especially 
those  of  the  lymphatic  glands,  perform  a  glandular  function, 
and  impress  important  changes  on  the  lymph  passing  through 
those  channels, 

Now  let  it  be  supposed  that  at  some  spot  the  lymphatic  net- 
work becomes  immensely  hypertrophied:  that  its  channels  be- 
come varicose  (as  it  were) :  that  the  contained  cells  assume  by 
degrees  the  property  and  function  of  the  cells  lining  the  lacteal 
ducts  and  lacteal  glands;  that  the  more  superficial  of  these  vari- 
cose enlargements  project  above  the  surface  of  the  skin  or  of 
the  urinary  mucous  membrane,  as  the  case  may  be;  and,  lastly, 
let  some  of  these  superficial  enlargements  become  ruptured  and 
discharge  their  contents  externally  or  into  the  urinary  passages, 
and  the  conditions  are  presented  for  the  production  of  chylous 
urine,  or  of  such  a  case  as  that  of  Robinson  and  others  of  a 
similar  class  to  which  reference  has  been  made  [see  p.  346,  foot- 
note). 

It  is  always  satisfactory  in  studying  an}^  rare  disease,  to  be 
able  to  refer  it  by  analogy  to  some  preexisting  well-known 
categorj^,  and  the  view  just  presented  of  the  pathology  of 
chylous  urine  and  the  allied  disorder  of  the  skin,  finds  its  exact 
analogy  in  those  hypertrophies  of  the  bloodvessels  which  con- 
stitute venous  nfevi,  erectile  tumors,  and  aneurisms  by  anasto- 
mosis— all  of  which  are  exaggerations  of  hypertrophies  of  the 
normal  arterial  or  venous  plexuses. 

It  rarely  or  never  happens  that  any  tissue  sufiners  morbid 
hypertrophy  without  some  degree  of  modification  of  its  normal 
structure;  and  the  hypertrophied  lymphatic  tissue  which  I  have 
suggested  as  one  cause  of  chylous  urine  and  the  allied  condition 
in  the  skin,  is  undoubtedly  modified  by  the  morbid  impulses 
which  generate  it.  Not  only  is  the  anatomical  structure  con- 
siderably altered  from  the  normal  type  of  lymphatic  tissue,  but 
the  function  of  the  cells  also  sufi'ers  a  modification.  The  cells 
which,  in  the  normal  state,  elaborate  lymph,  in  the  morbid  state 
come  to  produce  chyle,  or  a  fluid  intermediate  between  lymph 
and  chyle.  These  modifications  are,  however,  strictly  within 
the  limits  which  we  generally  find  in  other  morbid  hypertro- 
phies. 

A  new  and  important  light  has  been  thrown  on  the  pathology 
of  chyluria  and  those  cases  of  cutaneous  chylous  discharges 
which  occur  endemically  in  India,  by  the  researches  of  Dr. 
T.  R.  Lewis.  Dr.  Lewis  discovered  that  the  blood  and  urine 
of  patients  suffering  from  chylous  urine  contained  numbers  ot 


PATHOLOGY.  353 

actively  moving  microscopic  worms,  to  which  he  gave  the  name 
of  Filaria  sanguinis  hominis.  These  have  since  heen  shown  to 
be  the  embryos  of  an  adult  worm,  which  was  not  discovered 
until  some  time  afterwards.  The  reader  is  referred  to  (Jhap. 
XIII.,  Section  III.,  for  a  description  of  the  parasite  and  the  other 
symptoms  which  attend  its  presence  in  the  body.  In  a  post- 
mortem examination  of  a  case  of  chyluria,  Dr.  Lewis  found  in 
the  kidneys  vast  nund:>ers  of  filariee,  both  in  the  cortical  and 
pyramidal  portions.  There  were  also  found  '*  numerous  trans- 
lucent oil-like  tubules  of  a  somewhat  varicose  appearance  run- 
ning alongside  the  uriniferous  tubes  as  if  tlie  lymphatics  or 
minute  bloodvessels  of  the  part  had  been  plugged."  The  organs 
did  not  appear  otherwise  diseased. 

My  former  pupil.  Dr.  Bancroft,  now  practising  in  Brisbane, 
Queensland,  Australia,  informs  me  that  chyluria  is  not  uncom- 
mon in  that  colony.  He  has  detected  li]ari?e  both  in  the  urine 
and  in  the  blood  of  patients  so  affected,  and  has  also  discovered 
the  adult  worm  which  gives  rise  to  them. 

It  may  be  supposed  that  aggregations  of  these  little  animals 
in  the  kidneys,  or  some  other  part  of  the  urinary  tract,  give  rise 
to  rupture  of  the  lymphatics  and  a  leakage  of  their  contents 
into  the  urinary  channels,  and  in  this  way  produce  chyluria.  A 
further  account  of  the  life  history  of  the  parasite  will  be  found 
in  Chapter  XIII.,  to  which  the  reader  is  referred. 

The  following  abstract  of  Dr.  Mackenzie's  case  will  serve  to 
illustrate  the  course  of  chyluria  due  to  filarial  embryos,  and  is 
specially  interesting  from  the  completeness  of  the  observation, 
and  from  the  light  which  it  throws  upon  the  relations  of  the 
filarial  embryos  to  the  periods  of  the  disease : 

F.  H.  C,  aged  twenty-six,  was  born  at  Madras,  and  lived  in  India  up 
to  six  mouths  of  coming  under  the  care  ot  Dr.  Mackenzie.  About  one 
month  after  arriving  in  England  he  noticed  that  his  urine  was  increased 
in  quantity,  that  it  contained  clots,  and  appeared  slimy.  In  about  a 
week  the  urine  gradually  assumed  a  milky  appearance,  and  shortly 
became  as  "  white  as  milk."  On  May  6, 1881,  whilst  lying  down  in  the 
middle  of  the  day  he  was  seized  with  a  violent  pain  extending  from  the 
left  loin  to  the  left  testicle.  The  pain  lasted  for  about  twenty-one  hours, 
and  during  its  continuance  the  urine  was  of  a  deep  blood  color.  He 
gradually  lost  flesh,  the  urine  became  more  coi)ious,  and  formed  on 
standing  gelatinous  clots.  The  patient  was  admitted  into  the  London 
Hospital,  under  Dr.  Mackenzie,  on  August  11th. 

He  was  then  a  well-made,  healthy-looking  man.  His  appetite  was 
good,  but  he  slept  badly,  having  to  rise  frequently  to  pass  urine.  Xo 
disease  of  the  chest  or  abdomen  could  be  detected.  His  weight  was 
9  St.  1  lb.,  Avhile  on  arriving  in  England  it  was  11  st.  8  lbs.  The  urine 
resembled  rich  milk  mixed  with  a  little  blood.  A  few  minutes  after 
being  passed  it  coagulated  to  a  soft  tremulous  jelly,  the  coagulum  after- 

23 


354  CHYLOUS    UKINE. 

wards  breaking  down.  When  freshly  passed,  the  urine  had  a  sweet 
odor,  but  on  standing  became  fetid.  The  quantity  passed  daily  was  on 
the  average  120  ounces.  It  had  a  specific  gravity  of  about  1010,  was 
faintly  alkaline  or  neutral,  and  contained  no  sugar.  It  contained  albu- 
men. When  shaken  with  ether,  the  urine  lost  its  milky  character.  The 
day  urine  had  a  brownish  tint,  almost  completely  coagulated,  and  con- 
tained much  blood,  while  the  night  urine  was  more  milky,  did  not  form 
so  large  a  coagulum,  and  contained  less  blood.  Filarise  were  found  in 
the  urine  both  dead  and  alive.  The  blood  contained  large  numbers  of 
embryo  filarise  when  examined  at  night  time.  Between  9  a.m.  and  6 
p.  M.  no  filarise  were  found  ;  at  6  p.  m.  a  few  were  seen  ;  these  had  in- 
creased in  number  at  9  p.  m.,  were  in  the  greatest  number  at  midnight, 
and  gradually  decreased  in  number  up  to  9  A.  m.,  when  they  had  entirely 
disappeared.  At  night  it  was  computed  that  from  thirty-six  to  forty 
millions  of  filarial  embryos  were  present  in  the  blood. 

The  hours  of  meals  were  altered  to  four  hours  later  without  any  effect 
on  the  filarise,  but  the  day  and  night  urines  were  rendered  almost  alike 
Complete  reversion  of  the  hours  of  movement  and  rest,  and  correspond- 
ing change  in  the  meal  times,  caused  similar  reversion  in  the  filarial 
periodicity,  the  maximum  number  in  the  blood  being  then  found  at 
noon,  and  few  or  none  at  midnight. 

Under  treatment  the  patient's  health  improved  and  his  weight  in- 
creased. On  October  21st,  after  exposure  to  cold,  he  had  a  severe  rigor 
with  vomiting,  headache,  and  pain  in  the  epigastrium  and  right  hypo- 
chondrium.  Temperature  104°.  The  patient  coughed  without  expecto- 
ration, and  had  a  pain  in  the  right  side,  increased  on  coughing.  On 
October  23d  the  left  shoulder  was  tender  and  swollen.  Later  on,  a 
swelling  appeared  just  above  the  left  clavicle,  the  skin  over  which  was 
red.  This  increased  in  size,  gradually  assumed  the  characters  of  an 
abscess,  and  was  opened  antiseptically  on  November  4th,  pus  and  blood 
escaping.  Double  pleurisy  afterwards  developed  itself,  and  further  col- 
lections of  pus  formed  in  the  left  arm.  The  patient  gradually  lost  strength, 
and  died  on  January  10, 1882.  From  October  22d  no  filarise  were  found 
in  the  blood,  and  while  they  were  seen  as  usual  on  October  20th,  on  the 
21st  they  were  very  feeble  and  soon  died. 

At  the  autopsy  there  was  found  empyema  of  the  right  side,  and  on  the 
left  side  pleurisy.  The  right  lung  was  collapsed,  and  the  left  oedema- 
tous.  The  kidneys  showed  early  suppurative  nephritis  and  several 
wedge- shaped  patches  were  found  in  the  cortex.  The  thoracic  duct 
commenced  in  a  dense  mass  of  dilated  lymph  sinuses  extending  from 
the  bifurcation  of  the  aorta  below  to  the  aortic  opening  of  the  dia- 
phragm above.  The  thoracic  duct  was  pervious  for  1*  inch  above  the 
diaphragm,  then  filled  with  loose  clot  for  a  similar  distance,  after  which 
it  was  lost  in  a  tough,  thick  mass  which  was  apparently  of  inflamma- 
tory origin.  The  iliac,  lumbar,  and  renal  lymphatics  were  dilated,  but 
especially  those  in  the  left  renal  region. 

It  was  supposed  that  the  parent  worm  had  become  dislodged  in  the 
rigor,  and  becoming  impacted  in  the  thoracic  duct,  had  excited  inflam- 
mation, in  the  midst  of  which  it  perished. 


TREATMENT.  355 

Treatment. — Hitherto  the  treatment  of  this  disorder  has 
proved  very  unsatisfactory.  It  generally  persists  in  spite  of 
every  remedy,  or  disappears  without  any.  The  physicians  of 
Rio  chiefly  recommend  salt-water  baths,  and  iron  internally. 
Mineral  and  vegetable  astringents  have  been  tried  repeatedly 
with  small  evidence  of  success.  The  best  results  have  followed 
large  doses  of  gallic  acid.  Dr.  Waters  and  J)r.  Bence  Jones 
gave  from  one  to  two  drachms  a  day. 

Dr.  Bunyan,  of  George  Town,  British  Guiana  ("Lancet," 
1846,  I.  95),  relates  a  very  interesting  case,  in  which  the  disease 
had  lasted  ten  months.  Various  remedies  were  tried  without 
success.  On  the  advice  of  an  old  ncgress,  the  patient  took  a 
decoction  of  mangrove  bark  (Rhizophora  racemosa),  in  ounce 
doses,  four  times  a  day.  In  seven  days,  he  was  so  greatly  im- 
proved that  he  discontinued  the.  medicine  for  two  days,  when 
the  symptoms  returned.  The  medicine  was  resumed  in  in- 
creased quantity,  and  continued  for  several  days,  until  all  the 
symptoms  had  entirely  disappeared.  Afterwards  he  suffered 
two  returns  of  his  disorder,  which  were  immediately  cut  short 
by  the  use  of  the  mangrove  bark.  I  know  not  whether  the 
mangrove  bark  has  anti-parasitic  properties,  but  if  it  has  its 
success  in  the  treatment  of  chyluria  is  comprehensible.  It 
would  certainly  be  worth  a  trial  to  treat  cases  of  chyluria,  in 
which  filarise  are  found  in  the  blood,  by  anti-parasitic  remedies, 
and  especially  by  large  and  sustained  doses  of  the  iodide  of 
potassium. 

The  eft'ect  of  diet  was  investigated  by  Dr.  Bence  Jones.  He 
found  that  the  urine  was  somewhat  less  chylous  with  vegetable 
than  with  animal  food;  he  also  found  that  the  pressure  of  a 
tight  belt  round  the  loins  relieved  the  pains  in  the  lumbar 
regions,  and  seemed  to  improve  the  condition  of  the  urine  a 
little. 

Dr.  Dickinson,  in  his  case,  believing  that  the  chyluria  was 
due  to  regurgitation  of  chyle  from  the  thoracic  duct  into  the 
bladder,  applied  the  abdominal  tourniquet,  with  a  marked 
amelioration  of  the  condition  of  the  urine.  The  effect  of  indi- 
vidual applications  of  the  tourniquet  diminished  after  a  time, 
but  a  slight  permanent  improvement  was  observed.  The  chy- 
luria finally  ceased  after  the  use  of  injections  of  perchloride  of 
iron  into  the  bladder. 


PART  III. 

ORGANIC  DISEASES  OF  THE  KIDNEYS, 


CHAPTER    I. 

CONGESTION  OP  THE  KIDNEYS. 

Under  the  title  of  Congestion  of  the  Kidneys,  I  propose  to 
consider  those  less  serious,  and  for  the  most  part  secondary, 
renal  derangements  which  are  occasioned  either  by  an  undue 
determination  of  blood  to  the  organs  (active  congestion),  or 
some  mechanical  obstruction  to  the  return  of  blood  from  the 
organs  (passive  congestion). 

Renal  congestion,  both  active  and  passive,  if  sufficiently 
intense,  is  attended  by  the  presence  of  albumen  in  the  urine 
(generally  in  small  quantity),  sometimes  with  blood,  and  casts 
of  the  uriniferous  tubes.  Dropsy  is  not  a  symptom  proper  to 
renal  congestion;  when  present  it  depends  on  other  causes,  com- 
monly heart  or  lung  disease. 

Active  congestion  is  produced  by — overdoses  of  certain  irri- 
tants (cantharides,  turpentine,  etc.);  by  exposure  to  cold;  it  is  a 
common  instance  in  all  febrile  and  inflammatory  complaints;  it 
occurs  in  saccharine  diabetes;  probably  in  some  cases  of  hyper- 
trophy of  the  left  ventricle;  and  it  is  found  also  in  the  opposite 
kidney  when  one  kidney  has  become  disabled. 

Passive  congestion  accompanies — regurgitant  heart  disease; 
obstructions  in  the  lungs  (emphysema,  pleuritic  effusion);  pres- 
sure on  the  emulgent  veins  or  inferior  cava  (pregnancy,  abdomi- 
nal tumors). 

If  the  determining  cause  of  the  congestion  be  a  persistent 
one — as  in  valvular  heart  disease  or  diabetes,  organic  changes 
are  at  length  produced  in  the  kidneys,  which  bear  a  strong 
resemblance  to,  if  they  are  not  identical  with,  certain  forms  of 
B right's  disease. 

Accordingly,  several  of  the  conditions  here  considered  have 
been  arranged  by  other  writers  (Johnson,  Frerichs,  Griesinger, 


358  CONGESTION    OF    THE    KIDNEYS. 

Bamber2:er,  Wagner)  among  the  varieties  of  B right's  disease. 
But  although  there  are  unquestionable  affinities  between  the 
two  classes  of  cases,  there  are  also  differences  so  marked,  in  their 
symptoms,  progress,  and  general  clinical  history,  that  it  only 
tends  to  confusion  to  unite  them  under  one  heading. 

It  will  greatly  facilitate  our  comprehension  of  the  relations 
subsisting  between  certain  changes  in  the  composition  of  the 
urine,  and  certain  disturbances  of  the  renal  circulation,  if  we 
take  a  review  of  the  experimental  researches  which  have  been 
made  in  this  direction. 

Mr.  George  Robinson  was  the  first  to  demonstrate,  that  a 
complete  or  partial  impediment  to  the  return  of  blood  by  the 
renal  veins  caused  albumen,  blood,  and  sometimes  fibrin  to 
appear  in  the  urine.  He  operated  solely  on  rabbits.  In  one 
set  of  experiments,  he  placed  a  tight  ligature  round  the  renal 
vein :  in  a  second  set,  the  obstruction  was  made  incomplete — a 
certain  amount  of  blood  being  still  permitted  to  circulate 
through  the  kidneys.  In  both  these  sets  of  experiments  the 
urine  invariably  became  more  or  less  albuminous,  and  in  most 
cases  bloody.  The  kidney,  of  which  the  vein  had  been  thus 
obstructed,  M'as  in  every  instance  found  heavier  than  its  unin- 
jured fellow.  The  proportion  between  them  varied  from  1 J  :  1 
to  3  :  ] . 

Frerichs  repeated  these  experiments  on  dogs,  rabbits,  a  cat, 
and  a  frog,  with  identical  results.  In  four  out  of  ten  experi- 
ments, he  also  detected  casts  of  tubes  in  the  urine,  and  in  one, 
renal  epithelium.  Weissgerber  and  Perls,  Posner,  and  Ger- 
mont^  have  repeated  these  experiments  and  have  obtained 
similar  results. 

The  experiments  admit  of  easy  explanation.  The  blood 
accumulates  behind  the  impediment,  and  causes  an  increased 
lateral  pressure  upon  the  walls  of  the  renal  vein  and  its 
branches.  This  tension  is  transmitted  backward  to  the  renal 
capillaries,  which  are  thereby  distended,  and  their  walls  attenu- 
ated, creating  a  condition  highly  favorable  to  the  transudation 
of  the  serous  constituents  of  the  blood  through  their  coats.  If 
the  tension  be  sufficiently  great,  blood  corpuscles  escape  from 
the  vessels  either  by  diapedesis  or  actual  rupture,  and  pass  with 
the  albumen  into  the  urine.  It  is  probable  that  these  conse- 
quences take  efl"ect  earliest  in  the  tubules  of  the  medullary 
portion  of  the  kidney,  for  with  these  the  branches  of  the  renal 
vein  come  into  close  relation;  thence  the  pressure  is  transmitted 
through  the  renal  capillaries  to  the  Malpighian  clusters,  where 
there  exist  anatomical  facilities  for  ready  passage  of  blood  into 
the  urine.^     Cohnheim  is  of  opinion  that  it  is  not  the  mere 

1  Theie  De  Paris,  1882.         "  See  Senator,  Die  Albuminuric,  1882. 


EXPERIMENTAL    RESEARCHES.  359 

increase  in  blood-pressure  which  causes  alljuriien  to  transude, 
but  a  coincident  alteration  of  the  epithelium  covering  the  glo- 
merulus. 

Increased  pressure  in  the  arterial  system  does  not  so  easily 
cause  albumen  and  blood  to  appear  in  the  urine.  Kobinson 
sought  to  test  the  eftect  of  increased  arterial  pressure  on  the 
composition  of  the  urine,  by  directing  a  stronger  stream  of  blood 
than  natural  into  the  kidneys.  First  he  removed  one  kidney, 
thinking  that  the  physiological  determination  to  the  other  might 
suffice  to  cause  albuminuria.  The  experiment  was  repeated  five 
times,  and  only  in  one  instance  did  the  urine  become  albumi- 
nous. He  then  removed  one  of  the  kidneys  and  tied  the  abdo- 
minal aorta  below  the  origin  of  the  renal  arteries.^  In  this  way 
the  utmost  impulsion  of  blood  into  the  remaining  kidney  was 
obtained,  and  both  blood  and  albumen  invariably  made  their 
appearance  in  the  urine.  His  seventh  experiment  is  a  fair 
sample  of  his  results. 

Expt.  7.  The  left  kidney  of  a  middle-sized  rabbit  was  removed,  and 
weighed  54  grains.  The  aorta  was  then  tied  below  the  origin  of  the 
renal  arteries.  The  animal  was  killed  at  the  end  of  two  hours.  The 
right  kidney  weighed  85  grains ;  it  contained  six  or  seven  ecchymoses 
of  various  extent.  The  bladder  contained  about  a  drachm  of  urine, 
which  was  bloody  and  albuminous  (loc.  cit.,  p.  79). 

These  results  have  been  confirmed  by  Frerichs  and  Meyer. 

In  the  experiments  of  Hermann  and  Overbeck,  another 
method  of  inducing  artificial  albuminuria  is  pointed  out.  Her- 
mann's method  consisted  in  tying  up  the  renal  arteries  for  a 
short  time,  and  then  removing  the  ligature.  The  urine  which 
was  secreted  after  the  reestablishment  of  the  circulation  was 
always  found  albuminous.  Overbeck  interrupted  the  circula- 
tion in  other  ways.  In  one  set  of  experiments,  he  blew  up  a 
bladder  previously  introduced  empty  into  the  heart;  in  the 
second  set,  asphyxia  (and  consequent  arrest  of  the  blood-current) 
was  produced  by  compressing  the  trachea.  In  the  former  case 
the  obstruction  was  maintained  for  about  a  minute,  and  in  the 
latter  for  four  minutes.  In  both  classes  of  experiments,  the 
urine  which  first  flowed  after  the  renewal  of  the  circulation  was 
invariably  albuminous,  and  often  bloody.  The  albuminuria 
thus  provoked,  generally  lasted  a  few  hours,  and  then  passed 
away.  When  desquamation  of  the  renal  epithelium  occurred, 
it  always /o/foiyecJ  the  appearance  of  the  albumen.     It  could  not 

^  Tying  the  abdominal  aorta  without  removing  one  of  the  kidneys  was  per- 
formed twice  by  Eobinson  on  weak  animals;  in  one  only  did  albumen  appear  in 
the  urine.     Frerichs  states  that  he  could  onl3'  find  traces  of  albumen  in  a  few 
cases  afier  such  an  operation.     Me^^er,  on  the  other  hand,  saw  abundant  albumi 
nuria  follow  this  operation. 


3G0  CONGESTION    OF    THE    KIDNEYS. 

therefore  be  the  cause  of  it,  as  Johnson  surraised  to  be  the  case 
in  the  albuminuria  of  Bright's  disease. 

To  explain  the  results  obtained  by  Hermann  and  Overbeck, 
it  may  be  supposed  that  the  temporary  stoppage  of  the  blood- 
current  created  an  obstacle  in  the  renal  capillaries — probably  an 
accumulation  of  blood-corpuscles  in  the  Mai pighian  tufts — which, 
when  the  circulation  was  restored,  operated  to  raise  the  pressure 
in  the  minute  arteries;  in  other  words,  it  produced  active  con- 
gestion of  sufficient  intensity  to  cause  albumen  and  blood  to 
appear  in  the  urine.^ 

My  purpose  in  calling  attention  to  these  researches  is  to 
show,  that  simple  hyperaemia  or  congestion  of  the  kidneys 
(without  inflammation),  either  from  increased  impulsion  of 
blood  into  the  kidneys,  or  from  obstruction  to  the  return  of 
blood  from  the  kidneys,  is  sufficient  to  determine  the  appear- 
ance of  albumen  and  blood  and  even  fibrinous  casts  in  the 
urine. 

An  impeded  circulation  through  the  kidneys  cannot,  how- 
ever, long  persist,  without  inducing  serious  and  permanent 
structural  changes  in  the  organs.  The  presence  of  blood-cor- 
puscles, and  iibrinous  plugs,  in  the  delicate  tubular  structures, 
must  at  length  occasion  more  or  less  extensive  destruction  of 
these  structures;  and  the  continued  hypersemia  must  derange 
the  nutrition  of  the  glandular  elements.  How  far  these  changes 
are  of  an  inflammatory  nature,  cannot  be  precisely  indicated. 
One  of  the  most  important  results  of  a  long  continuance  of  this 
state  of  things  appears  to  be,  an  excessive  production  of  adven- 
titious connective  tissue,  which  eventually  passes  on  to  contrac- 
tion and  atrophy.  To  call  these  changes,  "  nephritis,"  is  to  use 
a  term,  which,  to  say  the  least,  is  calculated  to  mislead. 


ACTIVE   CONGESTIOlSr. 

{Catarrhal  Nephritis  of  Virchow.) 

In  the  course  of  eruptive  and  continued  fevers,  of  croup, 
diphtheria,  cholera,  erysipelas,  pyfemia,  acute  rheumatism,  pneu- 
monia, and  other  inflammatory  diseases,  the  kidneys  partake  in 
the  general  hyperaemia  of  the  internal  organs.  JSTot  unfre- 
quently,  however,  they  are  the  seat  of  a  disproportionate  deter- 
mination of  blood,  and  albumen  appears  in  the  urine.  Generally 
speaking,  the  amount  of  albumen,  in  such  cases,  is  a  mere  trace, 
but  sometimes  it  is  more  abundant,  and  accompanied  with  a  few 
blood-corpuscles,  transparent  casts  of  tubes,  and  scattered  renal 
epithelium.     There  may  be,  at  the  same  time,  some  tenderness 

'  For  other  possible  explanations,  see  p.  203. 


ACTIVE    CONGESTION.  361 

in  the  loins.  As  soon  as  defervescence  commences,  tiie  albumen 
diminishes,  and  in  a  few  days  vanishes  alto^^^ether. 

The  pathological  state  here  described  differs  from  genuine 
Bright's  disease,  which  may  likewise  arise  in  connection  with 
the  same  febrile  maladies,  in  the  absence  of  anasarca,  in  the  un- 
diminished excretion  of  urea,  and  in  the  period  of  its  invasion. 
Albuminuria  from  congestion  coincides  with  the  acme  of  the 
pyrexia,  and  subsides  therewith.  Genuine  Bright's  disease,  on 
the  contrary,  shows  itself  as  a  sequela,  toward  the  close  of  the 
pyrexial  stage  or  the  commencement  of  convalescence. 

An  examination  of  the  kidneys  of  persons  who  have  died 
from  the  primary  fever  while  laboring  under  renal  congestion, 
reveals  an  enlarged  and  engorged  condition  of  the  organs,  with 
minute  ecchymoses  on  the  surface,  and  great  engorgement  of 
the  stellate  veins.  A  large  amount  of  blood  flows  from  the  cut 
surface  of  the  kidney,  and  the  glomeruli  and  accompanying 
vessels  stand  out  as  red  points  and  streaks.  On  microscopic 
examination,  the  vessels  of  the  glomeruli  and  the  intertubular 
capillaries  are  swollen  and  gorged  with  blood-corpuscles,  while 
numerous  blood-corpuscles  are  seen  in  the  lumen  of  the  tubules 
and  between  the  glomerular  tuft  and  its  capsule ;  the  epithelial 
cells  are  swollen,  very  granular,  sometimes  show  signs  of  fatty 
changes,  and  are  frequently  detached. 

The  frequency  of  this  complication  in  zymotic  diseases,  varies 
in  different  epidemics.  Rosenstein  states  that  in  a  severe  typhus 
epidemic,  witnessed  by  him  in  1857,  the  majority  of  the  patients 
had  transient  albuminuria,  with  casts  of  tubes,  and  yet  no  serious 
consequences  followed  therefrom.  In  the  sporadic  typhoid  of 
this  city,  albuminuria  is  decidedly  rare. 

Active  renal  congestion  of  a  catarrhal  nature,  maj^  also  arise 
independently  of  any  specific  fever,  simply  from  exposure  to  cold. 
Such  cases  are  not  very  common,  or  perhaps,  as  Rosenstein  sug- 
gests, they  are  often  overlooked.  The  symptoms  resemble  those 
of  a  simple  febricula,  and,  unless  the  urine  chance  to  be  ex- 
amined, the  disorder  will  probably  be  passed  over  as  such.  The 
following  example  is  from  Rosenstein  : 

A.  B.,  oet.  39,  previously  healthy,  experienced  on  the  afternoon  of  the 
7th  of  October  a  chill,  followed  by  heat  and  severe  pains  in  the  renal 
region,  which  were  accompaui<=d  with  vomiting.  When  seen  she  was  in 
a  high  fever,  pulse  120,  very  thirsty,  and  without  appetite.  The  urine 
was  scanty,  acid,  albu'minous ;  after  standing,  it  deposited  a  sediment 
composed  of  uric  acid,  blood-corpuscles,  epithelial  casts,  and  free  epi- 
thelium. Pressure  on  the  renal  region  caused  pain.  She  was  cupped 
on  the  loins.  On  the  following  day  the  urine  measured  27  ounces, 
specific  gravity  1026,  otherwise  as  before  reported.  On  the  16th,  the 
pulse  was  92,  skin  moist  and  perspiring,  general  condition  good.  Urine 
in  twenty-four  hours,  28  ounces,  specific  gravity  1025,  acid,  free  from 


362  CONGESTION    OF    THE    KIDNEYS, 

albumen,  containing  only  a  few  casts.  On  the  succeeding  days  increased 
diuresis  in,  with  diminished  specific  gravity  of  the  urine.  The  urine 
continued  free  from  albumen  and  formed  elements  (p.  98). 

Cases  of  a  similar  nature  connected  with  subacute  rheumatism 
are  not  very  uncommon.  The  following,  which  I  saw  with  the 
late  Mr.  Mellor,  may  serve  as  an  example : 

The  patient  was  a  young  lady  of  26,  who  had  been  subject,  for  several 
years,  to  frequently  recurring  attacks  of  subacute  articular  rheumatism, 
which  kept  her  in  a  continuously  weak  state  of  health.  On  April  14th, 
she  took  cold  through  walking  in  the  wet,  and  was  seized  with  tonsillitis. 
As  this  subsided,  the  urine  was  noticed  to  be  bloody  and  to  contain  albu- 
men. On  the  15th  of  May  I  saw  her  for  the  first  time,  bhe  was  very 
pale  and  thin ;  there  was  considerable  fever,  pulse  108,  the  loins  were 
painful  and  very  tender  on  pressure,  skin  dry,  with  a  tendency  to  fre- 
quent vomiting.  Micturition  was  very  frequent  (20  times  a  day)  ;  the 
urine  amounted  to  three  pints  in  the  twenty-four  hours,  specific  gravity 
1010;  it  contained  a  good  deal  of  blood  and  albumen,  and  deposited 
uric  acid  very  abundantly.  The  copious  deposit  which  subsided  when 
the  urine  was  left  in  repose,  contained  numerous  large  transparent  casts 
(some  studded  with  epithelium)  and  much  free  renal  epithelium. 
Neither  casts  nor  epithelium  showed  any  signs  of  fatty  degeneration. 
There  was  also  found  a  large  number  of  pyelitic  cells.  Not  a  particle 
of  dropsy  or  anasarca  existed  in  any  part. 

The  patient  was  dry-cupped  over  the  loins,  after  which  hot  poultices 
were  directed  to  be  kept  (frequently  renewed)  to  the  same  region  ;  a 
compound  jalap  powder  was  administered,  and  a  citrate  of  potash 
mixture. 

In  four  days  the  fever  subsided,  the  pains  disappeared,  and  the  skin 
became  moist.  At  the  same  time,  the  urine  was  far  less  frequently 
passed,  and  it  contained  much  less  blood,  albumen,  and  casts.  It  still 
continued  abundant  in  quantity,  and  deposited  uric  acid  very  copiously. 

In  the  course  of  four  weeks,  convalescence  was  so  decidedly  estab- 
lished, that  the  patient  was  allowed  to  sit  up.  The  albumen  now  scarcely 
exceeded  "a  haze"  with  nitric  acid.  She  was  put  upon  a  phosphoric 
acid  mixture,  combined  with  phosphate  of  iron. 

On  June  24th  the  patient  suffered  a  relapse.  She  was  again  confined 
to  bed,  and  the  previous  treatment  put  in  force.  In  a  few  days  the 
feverish  symptoms  passed  off;  but  a  good  deal  of  blood,  albumen,  and 
renal  derivatives  continued  to  be  discharged.  She  was  now  put  upon 
gradually  increasing  doses  of  dilute  sulphuric  acid,  with  most  excellent 
effect.  The  urine  steadily  resumed  its  natural  characters,  and  the 
patient's  appetite  and  strength  began  to  return.    . 

On  the  24th  of  July  the  urine  had  become  free  from  albumen  and 
blood,  and  convalescence  was  thoroughly  established. 

The  case  was,  from  the  beginning,  regarded  as  distinct  from 
genuine  Bright's  disease,  and  considered  as  presenting  the  fea- 
tures of  a  catarrhal  (rheumatic?)  condition  of  the  pyramidal 


ACTIVE    CONGESTION.  363 

parts  of  the  kidneys,  combined  with  some  dcc^ree  of  subacute 
pyelitis.  The  total  absence  of  anasarca,  and  the  /2;eneral  ])or- 
traiture  of  the  complaint,  forbade  the  idea  of  acute  Bri^^ht's 
disease;  while  the  state  of  the  urine  and  tlie  progress  of  the 
case  ajipeared  inconsistent  with  the  chronic  forms  of  that  formid- 
able disorder. 

Certain  irritants  —  cantharides,  turpentine,  cubel)s,  copaiba, 
nitrate  of  potash,  and  carbolic  acid' — act  as  s|)ecial  stimuli  of 
the  urinary  organs;  and  excite,  when  administered  in  excessive 
doses,  liemorrhage  from  the  kidneys  and  the  lower  urinary  pas- 
sages. Johnson  relates  an  instance  in  which  half  an  ounce  of 
turpentine  was  taken  for  the  expulsion  of  tape-worm.  In  a  few 
hours  the  urine  was  bloody,  and  in  the  deposit  "blood-casts" 
were  discovered,  together  with  a  few  small  inflammatory  cells, 
but  no  epithelium.  Six  days  after,  the  urine  contained  less 
blood  and  albumen.  The  casts  of  tubes  were  still  visible,  and 
contained,  besides  the  blood-corpuscles,  a  large  proportion  of 
inflammatory  cells  about  twice  the  size  of  the  blood-corpuscles.^ 
The  patient  continued  to  pass  more  or  less  blood  for  some  days 
longer.  On  the  sixteenth  day  the  urine  was  free  from  albumen 
and  blood, 

Bouillaud  examined  the  effects  of  cantharides  acting  through 
the  skin.  He  states  that,  almost  constantly,  when  large  blisters 
were  applied  to  scarified  portions  of  the  skin,  albumen  appeared 
in  the  urine.  After  death,  he  found  the  mucous  membrane  of 
the  pelvis  and  ureters,  in  other  cases  that  of  the  bladder,  in- 
jected, and  covered  here  and  there  with  false  membranes.  The 
kidneys  were  generally  stroHgly  congested  and  studded  with 
minute  ecchymoses.  Albuminuria  after  cantharides  usually- 
disappeared  in  tw^o  or  three  days ;  in  a  few  cases  it  lasted  four 
weeks. 

Two  cases  of  poisoning  by  sulphuric  acid  are  related  by 
Leyden  and  Munk,  in  which  albumen  and  casts  appeared  in 
the  urine. ^ 

Cases  have  also  been  described  in  which  the  external  appli- 
cation of  tincture  of  iodine,  of  styrax,  and  of  petroleum,  have 
given  rise  to  albuminuria. 

Frerichs  enumerates  irritants  of  this  class  among  the  exciting 
causes  of  genuine  Bright's  disease;  and  brings  forward  two 
cases  by  Eeinhardt,  in  which  abuse  of  copaiba  and  cubebs  was 

1  Quinine  in  very  rare  cases  produces  congestive  liEematuria.  This  effect  ap- 
pears ti)  be  due  to  an  idiosyncrasy.  I  liave  known  one  such  person.  Two  cases 
are  also  reported  in  the  Brit.  Med    Journ.  for  Januarj',  1870. 

^  Were  not  these  renal  epithelia? 

3  Archiv  f.  path.  Anat  ,  Bd.  xxii.  S.  237.  Hydrochloric  acid  also  caused  albu- 
men, casts,  and  blood  to  appear  in  the  urine,  in  a  case  reported  by  Gehle,  Berlin, 
klin.  Wochenschr.,  1884,  No.  22. 


3(i4  CONGESTION    OF    THE    KIDNEYS. 

followed  by  renal  degeneration,  which  in  one  of  them  proved 
fatal.  These  cases  are,  however,  as  Rosenstein  points  out,  in- 
conclusive, because  it  is  probable  that  the  kidneys  were  already 
diseased  before  the  use  of  the  irritants  was  commenced. 

More  recent  experiments  have  shown,  that  genuine  organic  change  in 
the  kidneys  may  be  produced  by  the  internal  administration  of  irritants  ; 
although  the  exact  nature  of  the  change  is  a  matter  of  dispute  amongst 
the  several  observers.  Cornil,^  by  giving  cantharides  to  animals,  pro- 
duced marked  alterations  in  the  epithelial  cells,  such  as  are  found  in 
parenchymatous  nephritis.  The  cells  were  swollen,  completely  filled 
the  lumen  of  the  tubules,  and  contained  fat  granules  and  occasionally 
red  blood-corpuscles.  In  many  cells,  too,  e;lobules  of  a  hyaline  material 
were  seen.  Similar  epithelial  changes  were  found  by  Browicz.^  Dunin* 
describes  changes  in  the  cells,  due  to  "coagulative  necrosis."  Aufrecht,^ 
on  the  other  hand,  found  interstitial  nephritis,  and  succeeded  in  pro- 
ducing even  a  granular  kidney.  It  is  probable  that  the  nature  of  the 
change  depends  on  the  dose  of  the  poison  and  the  method  of  its  admin- 
istration, small  doses  producing  mere  congestion,  larger  doses  the  epithe- 
lial changes,  while  small  doses  given  repeatedly  cause  an  overgrowth  of 
interstitial  tissue. 

In  a  previous  section  it  has  been  mentioned,  that  in  the  later 
periods  of  diabetes,  albumen  not  unfrequently  appears  in  the 
urine.  The  excessive  action  of  the  kidneys  in  this  disease,  keeps 
up  a  constant  congestion  of  the  organs:  and,  in  the  course  of 
time,  permanent  anatomical  changes  follow — degeneration  of  the 
epithelium,  increase  of  interstitial  tissue,  development  of  cysts, 
and  other  structural  alterations,  w^hich  are  sometimes  classified 
with  genuine  B right's  disease. 

There  is  yet  one  other  condition  which  seems  capable,  in  rare 
instances,  of  producing  an  active  congestion  of  the  kidneys, 
sufficiently  intense  to  determine  albuminuria.  In  the  compen- 
satory hypertrophy  of  the  left  ventricle,  which  follows  aortic 
regurgitant  disease,  the  propulsion  of  blood  into  the  aorta  (when 
the  orifice  is  patulous)  takes  place  with  very  great  force;  and  the 
tension  of  the  arterial  system  at  the  close  of  the  ventricular  sys- 
tole, rises  considerably  above  the  normal  maximum,  as  is  indi- 
cated by  the  full  resistant  pulse.^     Practically,  however,  albu- 

1  Journal  de  I'Anatomie,  1879,  p.  402. 

2  Centralb.  f.  Med.  Wissensch.,  1879,  p.  145. 
»  Virch.  Archiv,  vol.  93,  p.  318. 

*  Centralb.  f.  Med.  Wissensch.,  1882,  p.  849. 

^  It  is  not  probable  that  the  mean  lateral  pressure  in  the  arterial  system  can 
ever  be  raised  above  the  normal  degree  in  compensatory  hypertrophy  of  the  left 
ventricle  ;  but  it  is  quite  conceivable  and  agreeable  to  clinical  facts,  that  the  maxi- 
mum tension  (attained  at  the  close  of  the  systole)  may  be  excessive,  and  be 
counterbalanced,  or  more  than  counterbalanced,  by  undue  diminution  of  tension 
during  the  ventricular  diastole. 


PASSIVE    CONGESTION.  'J65 

minuria  traceable  to  hypertrophy  of  this  kind,  is  rare.  I  have 
repeatedly  examined  the  urine  of  persons  with  irnrncnHC  enlarge- 
ment of  the  left  heart,  without  finding  albumen  in  more  than 
three  or  four  instances.  The  following  is  one  of  these,  in  which 
no  tenable  explanation  of  the  albuminuria  could  be  found  except 
renal  congestion  from  excessive  power  of  the  left  ventricle. 

T.  H.,  set.  21,  a  warehouseman,  came  under  treatment  February,  1864, 
suffering  from  immense  cardiac  hypertrophy.  The  apex  beat  in  the 
seventh  interspace  almost  in  the  axillary  line,  and  seven  and  a  half 
inches  from  the  mid-sternal  base.  The  impulse  was  strong;  the  whole 
body  shook  at  each  beat  of  the  heart.  The  pulses  were  visible  in  all 
the  superficial  arteries.  A  loud  to-and-fro,  roughish  murmur  was  heard 
over  the  aortic  cartilage,  of  which  the  diastolic  part  was  greatly  pro- 
longed. This  murmur  was  heard  loudly  at  the  base,  but  grew  weaker 
toward  the  apex — beyond  which  it  ceased  to  be  audible.  The  valvular 
mischief  seemed  to  be  confined  to  the  aortic  orifice.  There  was  no  sign 
of  serious  mitral  regurgitation  nor  any  indication  of  impediment  on  the 
right  side  of  the  heart.  There  was  total  absence  of  a  cyanotic  tint;  on 
the  contrary,  the  face  was  pinkish  pale,  and  the  margin  of  the  lips  and 
tongue  were  of  a  faint  rose;  there  was  no  swelling  of  the  veins  of  the 
neck  nor  a  trace  of  anasarca.  On  the  other  hand,  the  pulse  was  hard, 
resistant,  bisferiens,  ranging  from  92  to  104.  The  character  of  the 
urine  was  highly  significant.  It  was  not  high-colored  and  scanty,  as  in 
venous  congestion,  but  abundant,  pale,  and  of  low  specific  gravity.  The 
daily  discharge  varied  ftom  57  to  65  ounces,  the  specific  gravity  from 
1010  to  1015.  It  contained  albumen,  but  only  in  small  quantity ;  gen- 
erally only  a  haze  was  produced  with  nitric  acid  ;  no  tube-casts  or  other 
renal  derivatives  could  be  detected,  though  often  looked  for.  It  was 
distinctly  observed  that  the  proportion  of  albumen  oscillated  in  accord- 
ance with  the  activity  of  the  heart.  When  the  ventricle  was  in  high 
action  the  albumen  rose ;  when  it  became  more  quiescent,  under  the 
influence  of  rest  and  digitalis,  the  albumen  almost  vanished  for  a  time. 
I  have  recently  seen  this  patient  again  (March,  1865)  and  find  that  his 
state  is  still  as  above  described  ;  there  is  a  trace  of  albumen  in  the 
urine  ;  but  the  general  condition  is  wonderfully  good. 

The  treatment  of  active  renal  congestion  will  be  described 
with  that  of  passive  congestion,  at  the  end  of  the  next  section. 


PASSIVE  CONGESTION. 

The  experiments  of  Eobinson  and  Frerichs,  already  cited, 
show  that  an  impediment  or  obstruction  to  the  return  of  blood 
from  the  kidneys  induces  passive  congestion  of  these  organs, 
and,  if  sufficiently  intense,  causes  albumen  and  blood  to  appear 
in  the  urine.  An  impediment  of  minor  degree  does  not  render 
the  urine  actually  albuminous,  but  causes  it  to  become  scanty, 
high-colored,  dense,  and  prone  to  deposit  abundance  of  lithates. 


366  CONGESTION    OF    THE    KIDNEYS. 

Both  these  degrees  of  obstruction  are  frequently  witnessed  in 
clinical  experience. 

The  obstruction  may  be  seated  in  the  chest,  as  in  cases  of 
valvular  heart  disease,  emphysema,  and  pleuritic  effusion :  or 
in  the  abdomen,  as  when  a  gravid  uterus  or  other  tumor  presses 
upon  the  emulgent  veins  or  the  upper  course  of  the  inferior 
cava.  Sometimes  a  cirrhotic  liver  compresses  the  latter  vein  as 
it  lies  in  the  hepatic  fossa. 

The  alterations  on  the  side  of  the  urine  are  not  always  pro- 
portional to  the  degree  of  obstruction  to  the  circulation.  Cases 
are  met  with,  in  which  venous  stagnation  exists  in  an  intense 
degree,  with  dropsy,  orthopncea,  and  pulsating  jugulars,  with- 
out a  trace  of  albumen  in  the  urine,  and  others  in  which  the 
urine  changes  are  strongly  marked,  while  the  more  general 
symptoms  of  venous  obstruction  are  only  moderately  so. 

The  two  examples  which  follow,  afford  good  illustrations  of 
an  unusual  degree  of  renal  derangement,  secondary  to  obstruc- 
tion to  the  circulation  within  the  chest.  In  the  first  case  the 
obstruction  was  due  to  old-standing  tricuspid  regurgitation;  in 
the  second  to  extensive  emphysema. 

Case  1. — A  lawjer's  clerk,  set.  44,  came  under  observation  December 
6,  1862.  He  was  suffering  from  oedema  of  the  legs,  ascites,  and  a 
severe  bronchial  attack.  The  features  were  livid  ;  but  the  veins  of  the 
neck  wer-e  not  distended.  The  heart's  apex  beat  in  the  fifth  interspace, 
a  little  outside  the  nipple  line.  The  cardiac  dulness  extended  four 
inches  vertically,  and,  about  the  same  diagonally  from  base  to  apex. 
The  heart's  action  was  very  irregular  both  in  force  and  rhythm  ;  pulse 
was  104.  A  loud  blowing  murmur  was  heard  at  the  apex,  of  mitral 
regurgitant  character,  associated  with  a  faint  diastolic  bruit,  which  was 
heard  in  maximum  intensity  over  the  second  right  costal  cartilage. 
Loud  bronchitic  rales  were  heard  universally  over  both  lungs.  There 
was  copious  mucous  expectoration,  sparsely  speckled  with  blood  ;  also 
severe  dyspnoea,  amounting  at  times  to  orthopnoea. 

The  urine  was  scanty,  reddish,  specific  gravity  1025,  with  abundant 
clouds  of  lithates.  It  contained  a  small  quantity  of  albumen  (equal  to 
about  i).  The  deposit,  examined  under  the  microscope  (see  Fig.  49), 
revealed  numerous  scattered  blood-disks  ;  casts  of  tubes,  mostly  per- 
fectly hyaline,  sometimes  only  visible  when  tinted  with  magenta;  some 
casts  were  dotted  with  withered  renal  epithelia  or  with  the  nuclei  of 
these;  no  oily  or  fatty  particles  were  found. 

On  tracing  back  the  patient's  history,  it  appeared  that  he  had  had 
five  attacks  of  acute  articular  rheumatism,  of  which  the  earliest  occurred 
in  his  twentieth  year.  In  one  of  these  the  heart  had  become  affected. 
The  cyanotic  appearance  and  dropsical  symptoms  had  shown  themselves 
some  months  previously,  but  had  suddenly  assumed  a  formidable  in- 
tensity a  fortnight  before,  in  consequence  of  a  bronchitic  attack. 

With  rest  and  other  appropriate  means,  the  bronchial  attack  subsided 
in  about  ten  days.    The  dropsical  and  dyspnoeal  symptoms  receded,  and  a 


PASSIVE    CONGESTION, 


367 


moderatelj'  quiescent  state  was  attained.  The  urine  underwent  corre- 
sponding change  ;  it  became  more  copious,  its  density  fell,  and  the  albu- 
men faded  to  a  mere  trace  ;  the  casts  ren)ained  as  before. 

While  under  observation  this    man   went  through   three  bronchitic 
attacks.     In  each,  the  urine  went  back  to  the  character  given  of  it  in 


Fig.  49. 


Casts  of  tubes  and  blood-oorpuscles  from  the  urine  of  a  patient  witli  passive  renal  congestion. 

the  first  report.  In  the  intervals  again,  the  albumen  became  very- 
scanty,  and  on  two  occasions  the  urine  was  found  altogether  free  from 
albumen. 

Case  2.-— On  October  16, 1862,  a  strongly  built,  stout  woman,  set.  42, 
was  admitted  into  the  Manchester  Infirmary,  almost  in  a  state  of  asphyxia. 
She  was  intensely  blue  in  the  face;  could  only  breathe  in  the  upright 
posture  ;  her  voice  was  a  faint  husky  whisper;  the  tongue  was  livid;  the 
veins  of  the  neck  were  enormously  dilated  ;  she  looked  like  a  person  half 
choked.  There  was  not  a  particle  of  oedema  nor  any  ascites  ;  the  limbs 
were  firm  and  muscular.  There  was  considerable  drowsiness,  but  no 
actual  coma.  The  sputum  was  frothy,  not  bloody.  The  examination  of 
the  chest  revealed  extensive  capillary  bronchitis,  in  emphysematous 
lungs  ;  both  bases  were  somewhat  dull.  There  were  no  cardiac  mur- 
murs; the  superficial  cardiac  dulness  was  inappreciable  on  account  of 
the  emphysema. 

The  urine  was  dusky  red,  and  gave  a  play  of  colors  with  nitric  acid 
(showing  bile)  ;  no  sugar  in  it;  it  was  albuminous  to  a  considerable  de- 
gree (^).  In  the  sediment,  which  was  abundant  and  composed  of  lithates, 
were  found  numerous  tube  casts— nearly  all  hyaline;  some  of  them 
studded  here  and  there  with  altered  epithelium,  or  altered  blood-disks ; 
a  number  of  free  cells  were  also  found,  most  of  them  pus  corpuscles,  but 
some  with  solitary  nuclei— evidently  renal,  and  very  little  altered  from 
their  natural  appearance.  One  cast  was  seen  so  studded  with  these  as 
to  deserve  the  name  of  an  epithelial  cast.  Not  a  particle  of  fat  was 
found  in  the  renal  derivatives. 


368  CONGESTION    OF    THE    KIDNEYS. 

On  the  next  day  but  one  (October  1 8)  the  patient  seemed  to  breathe 
a  little  easier,  but  the  surface  was  still  intensely  cyanotic.  Of  the  urine, 
the  notes  state :  "  somewhat  less  highly  colored ;  very  much  less  albu- 
minous, in  fact  the  urine  only  becomes  hazy  with  nitric  acid  ;  casts  and 
cells  still  abundant." 

Next  day  the  breathing  seemed  again,  if  anything,  rather  easier,  but 
the  strength  was  evidently  failing,  and  the  drowsiness  was  becoming 
deeper.  The  urine  no  longer  showed  any  bile  tints,  though  still  of  a 
deep  brown  color.  Albumen  could  only  be  discovered  in  it  by  very 
careful  testing ;  the  casts  had  all  but  disappeared  ;  a  few  short  frag- 
ments (slightly  more  granular  than  before)  could  with  difficulty  be 
found  and  identified.  A  few  blood-corpuscles  were  seen  after  diligent 
searching. 

October  20th. — There  was  evident  emaciation  going  on,  and  steady 
diminution  of  strength.  Scarcely  any  nourishment  had  been  taken 
since  admission  ;  the  voice  was  whispering,  and  the  surface  livid.  The 
dyspnoeal  symptoms  were  at  a  standstill;  drowsiness  on  the  increase. 

21st. — The  urine  was  now  quite  free  from  albumen,  and  no  casts  could 
be  found  in  the  deposit.  In  the  course  of  the  succeeding  night  the 
patient  quietly  died,  as  if  in  sleep,  partly  exhausted  by  want  of  nourish- 
ment and  the  efforts  to  breathe,  partly  poisoned  by  the  raephitic  condition 
of  the  blood. 

Autopsy,  18  hours  after  death.  The  heart  weighed  eleven  ounces ;  the 
valves  were  healthy  ;  a  few  slight  atheromatous  patches  existed  in  the 
aorta.  The  lungs  were  in  a  state  of  excessive  and  universal  emphy- 
sema ;  they  bellied  out  of  the  cavities,  when  the  chest  was  opened,  like 
bladders  of  air.  Spots  of  intense  congestion  were  found  here  and  there 
on  section,  and  the  extreme  bases  were  somewhat  oedematous.  The  liver 
was  enlarged  and  congested.  The  kidneys  were  considerably  enlarged, 
and  weighed  together  tAvelve  ounces ;  the  capsules  peeled  off  readily. 
On  section  the  pyramidal  and  cortical  substances  were  distinct  from 
each  other,  and  in  due  proportion  ;  both  parts  were  intensely  congested, 
but  otherwise  natural,  both  to  the  naked  eye  and  to  microscopical  ex- 
amination. The  body  was  still  moderately  well  nourished ;  there  was 
no  anasarca  in  any  part,  nor  any  ascites. 

There  is  one  circumstance  in  this  history  v^hich  at  first  sight 
appears  contradictory,  namely,  the  disappearance  of  the  albu- 
men from  the  urine,  notwithstanding  that  the  obstruction  in  the 
chest  persisted  or  even  increased,  and,  indeed,  brought  the  cir- 
culation ultimately  to  a  standstill.  The  explanation  of  this 
occurrence  is,  I  believe,  to  be  found  in  the  diminishing  pressure 
in  the  arterial  system  from  the  gradual  failure  of  the  heart's 
power.  Some  of  Robinson's  experiments  bear  clearly  on  this 
point.  He  found,  on  ligaturing  the  renal  veins  in  rabbits,  that 
vigorous  animals  exhibited  the  urine  changes  (albuminuria,  etc.) 
in  far  greater  intensity  than  ?(jm^er  animals;  and  he  attributed 
the  difference  to  the  fact  that  in  strong  animals  the  powerful 
contractions  of  the  ventricle  served  to  maintain  a  greater  coun- 
ter-pressure on  the  arterial  side  of  the  renal  circulation,  and  in 


TREATMENT.  369 

this  way  intensified  the  intrarenal  pressure  or  congestion.  In 
the  patient  before  us  the  pressure  on  the  arterial  side  was  visibly 
declining  from  day  to  day,  in  conse({uence  of  tlie  inability  tfj 
take  food,  which  diminished  tlie  mass  of  the  blood,  and  the 
progressive  poisoning  of  the  blood  (from  defective  respiration) 
which  gradually  depressed,  and  finally  annihilated  the  con- 
tractility of  the  ventricle. 

The  state  of  the  kidneys  in  passive  congestion  varies  with  the 
duration  of  the  obstruction.  When  the  obstruction  has  been 
only  recently  established,  as  in  the  woman  whose  case  has  just 
been  related,  the  kidneys  are  found  simply  enlarged  and  en- 
gorged; they  resemble  the  kidneys  of  the  rabbit,  whose  renal 
veins  were  ligatured  by  Robinson.  They  are  dark  in  color,  and 
on  section  a  large  quantity  of  dark  blood  exudes  from  the  cut 
surface.  Although  the  whole  of  the  surface  is  redder  than  nor- 
mal, yet  the  congestion  is  seen  to  be  most  marked  in  the  pyra- 
midal portion,  where  dark  red,  almost  black  streaks  run  from 
the  apex  to  the  base  of  each  pyramid.  The  Malpighian  corpus- 
cles do  not  present  the  prominence  seen  in  active  congestion. 
On  microscopic  examination  the  veins  and  capillaries  are  found 
to  be  gorged  with  blood-corpuscles,  while  round  the  vessels  red 
blood-corpuscles  may  be  seen  in  the  neighboring  tissue,  and 
even  in  the  tubules  themselves.  The  tubules  in  many  places 
contain  hyaline  casts,  and  the  epithelium  is  usually  granular 
and  sometimes  fatty.  But  when  the  congestion  has  been  in 
existence  for  months  or  years,  the  kidneys  are  found  to  have 
undergone  far  more  profound  alterations.  The  organs  may 
then  be  somewhat  smaller  than  normal,  but  are  invariably  hard 
and  tough.  The  external  capsule  usually  peels  off  easily,  and 
leaves  on  removal  a  smooth  or  slightly  granular  surface.  On 
section,  the  same  congested  state  of  the  pyramidal  portion  is 
observed.  The  proportion  of  cortical  to  pyramidal  substance  is 
not  much  altered,  but  in  very  chronic  cases  the  cortex  may  be 
somewhat  atrophied.  On  microscopic  examination,  the  most 
characteristic  lesion  is  a  great  increase  on  the  interstitial  tissue 
between  the  tubules  and  round  the  glomeruli.  This  tissue  is 
composed  of  fully  formed  fibrous  tissue,  containing  but  few  cells: 
the  basement  membrane  of  the  tubules  is  also  thickened  and' 
passes  into  the  thick  interstitial  tissue.  The  walls  of  the  arteries 
are  thickened,  but  there  is  no  endarteritis  seen.  The  convo- 
luted tubules  themselves  are  some  contracted,  some  dilated,  and 
their  cells  are  usually  small  and  cubical. 

The  exact  nature  of  these  latter  alterations  is  a  matter  of 
dispute.  Frerichs,  Bergson,  and  Bamberger  consider  them  as 
identical  with  those  in  the  granular  kidney  of  Bright's  disease; 
but  Traube  contended  that  they  were  essentially  different. 
Cornil  is  also  of  opinion  that  the  lesion  is  not  a  nephritis. 

24 


370  CONGESTION    OF    THE    KIDNEYS. 

Whatever  anatomical  difficulties  there  may  be  in  the  way  of 
separating  these  cases  from  chronic  Bright's  disease;  the  clinical 
distinctions  between  them  are  clear  and  undoubted.  Renal  dis- 
order from  passive  congestion  comports  itself  quite  diiierently 
from  Bright's  disease  of  independent  origin,  and  from  Bright's 
disease  coming  on  in  the  course  of  chronic  disease  of  bone  or 
phthisis.  The  contrast  between  the  first  and  the  third  is  very 
marked.  In  the  first  (passive  congestion),  the  renal  affection 
has  no  momentum  of  its  own,  and  makes  no  independent  prog- 
ress; it  oscillates  with  the  rising  and  falling  intensity  of  the 
venous  obstruction ;  it  remains  throughout  a  subsidiary  com- 
plication of  the  primary  disease,  and  assumes  none  of  the 
special  characteristics  of  Bright's  disease  (ursemia,  etc.).  On 
the  other  hand,  when  renal  disease  declares  itself  in  the  course 
of  chronic  phthisis,  it  assumes  at  once  a  formidable  position. 
The  entire  clinical  complexion  of  the  case  is  transformed. 
Sometimes  even  the  pulmonary  disorder  is  altogether  supplanted 
and  thrown  into  the  background  by  the  more  rapid  progress 
and  fatal  course  of  the  renal  disease.  [See  case  of  M.  C.  in 
Chapter  IV.) 

Treatment  of  Congestion  of  the  Kidneys. — Congestion  of 
the  kidneys,  whether  active  or  passive,  does  not  often  call  for 
separate  treatment.  Its  course  and  intensity  are  usually  con- 
tingent on  the  progress  of  the  primary  disorder  of  which  it  is  a 
secondary  phenomenon.  But  sometimes  active  congestion  has 
an  independent  origin ;  in  other  cases,  although  secondary,  it  is 
sufficiently  threatening  to  demand  special  attention.  Passive 
congestion  from  cardiac  and  pulmonary  obstructions  can  be 
most  efficiently  relieved  by  remedies  applied  to  the  primary 
complaints.  But  passive  congestion  from  the  pressure  of  a 
pregnant  uterus — cases  which  will  be  considered  at  length  in 
the  appendix  to  this  chapter — not  unfrequently  claims  energetic 
treatment  on  its  own  account. 

The  most  efficient  means  of  combating  active  renal  conges- 
tion are  complete  rest  of  the  body,  cupping  the  loins,  brisk 
purgatives,  the  warm  bath,  and  other  diaphoretics.  In  the 
passive  cases,  cupping  can  only  be  of  service  when  the  conges- 
tion is  due  to  a  temporary  cause,  such  as  pregnancy;  in  the 
more  common  cases,  the  application  of  gentle  counter-irritants 
to  the  loins  is  more  serviceable,  namely,  tincture  of  iodine, 
embrocations,  etc.  Derivation  by  the  bowels  and  skin  is  also 
an  important  means  of  relieving  the  overloaded  organs. 


APPENDIX.  '371 


APPENDIX. 

071  the  connection  oj   renal  congestion,  albuminuria,   and  BrighVs 
disease,  lolth  pregnancy  and  jnierperal  eclampsia. 

The  late  Sir  J.  Simpson  was,  1  believe,  the  first  to  call  atten- 
tion to  the  occasional  presence  of  albumen  in  the  urine  of  preg- 
nant women.  The  subject  has  since  been  studied  on  many 
hands  with  a  view  to  elucidate  the  connection  of  the  puerperal 
state,  and  especially  of  puerperal    convulsions,  with    Bright's 

Albuminuria  does  not  usually  show  itself  in  pregnancy  until 
the  seventh  or  eighth  month,  and  often  not  until  the  approach 
of  labor.  Sometimes,  however,  it  appears  earlier,  even  so  early 
as  the  third  month.  It  is  generally  attended  with  oedema  of  the 
lower  extremities,  sometimes  also  of  the  face  and  upper  parts  of 

the  body.  •    i      r 

Blot  found  among  the  patients  of  a  lying-in  hospital,  that 
one  pregnant  woman  in  five  had  albumen  in  the  urine:  this 
estimate'is  evidently  very  much  too  high  for  a  general  average. 
Abeille  found,  in  private  practice,  the  proportion  to  be  one  in 
ten ;  and  Vans  Arsdale  and  Elliott,  one  in  fifty-six.  ("  :N'ew  York 
Journ.  of  Med.,"  1856.)  This  last  estimate  is  probably  the  most 
nearly  correct. 

The  albuminuria  of  pregnancy,  and  the  accompanying  ana- 
sarca, usually  go  on  increasing  up  to  the  time  of  delivery,  and 
then  rapidly  pass  away.  As  a  rule,  the  albumen  is  quite  gone 
in  forty-eight  hours,  sometimes  even  in  twenty-four  hours ;  but 
it  may  not  wholly  disappear  for  ten  or  fifteen  days.  If  it  con- 
tinue beyond  this  last  period,  the  gravest  apprehensions  of 
organic  renal  disease  are  justified. 

The  urine  in  the  condition  in  question  is  usually  scanty,  of 
high  specific  gravity  and  dark  color,  contains  a  large  quantity 
of  albumen  and  a  'little  blood,  and  deposits  hyaline  tube-casts 
and  urates  on  standing.  Hiller  found  in  one  case  crystals  of 
haematoidin. 

If  we  inquire  into  the  origin  of  albuminuria  m  pregnancy, 
two  conditions  present  themselves,  which,  altogether  or  sepa- 
rately, are  capable  of  explaining  its  occurrence :  these  are-  (a) 
alterations  in  the  circulation  of  blood  through  the  kidneys,  and 
(b)  the  alterations  in  the  quality  of  the  blood  which  are  proper 
to  the  pregnant  state. 

The  older  observers,  and  perhaps  the  majority  of  tlie  modern 
writers,  are  of  opinion  that  the  principal  change  in  the  circula- 
tion of  the  kidney  is  passive  congestion  due  to  pressure  of  the 
uterus  on  the  renal  veins.    According  to  this  view,  the  growing 


372  CONGESTION    OF    THE    KIDNEYS. 

womb  mounting  into  the  abdomen  necessarily  exercises  a 
certain  compression  on  the  contents  of  that  cavity,  and  among 
other  structures,  on  the  inferior  cava  and  renal  veins.  This 
mechanicaV  pressure  occasions  a  passive  congestion  of  the  kid- 
neys, which,  if  sufficiently  severe,  induces  albumen  to  appear  in 
the  urine,  together  with  blood  and  tube-casts.  That  this  is  one 
of  the  most  efficient  causes  of  albuminuria  in  pregnancy,  is 
indicated  by  the  fact  that  primiparse,  in  whom  the  parts  are 
resistent,  and  the  pressure  therefore  intense,  are  disproportion- 
ately liable  to  albuminuria;  so,  too,  albuminuria  is  common 
where  the  liquor  amnii  is  in  excess ;  and  in  twin  pregnancies 
also  albumen  does  not  usually  appear  in  the  urine  until  the  later 
periods  of  gestation,  when  the  venous  stagnation  has  reached 
its  height. 

The  recent  observations  of  Le3^den  have,  however,  caused 
doubts  as  to  the  correctness  of  the  above  view.  From  the 
results  of  several  autopsies  he  showed  that  the  kidney  if  ex- 
amined soon  after  delivery  was  large,  the  cortex  swollen,  pale 
and  ancemic,  and  that  the  epithelium  had  undergone  advanced 
fatty  change.  When  examined  at  a  greater  interval  from  the 
delivery,  the  kidney  was  still  pale,  but  had  lost  its  swollen  and 
fatty  condition. 

The  urine,  too,  differs  from  that  of  venous  congestion  of  the 
kidneys,  in  containing  a  large  instead  of  a  small  quantity  of 
albumen. 

Leyden's  description  of  the  kidneys  has  since  been  confirmed 
by  Hiller,  but  the  cause  of  the  anaemia  of  these  organs  is  not 
clear.  ^ 

Flaischlen  has  suggested  that  the  anaemia  may  be  due  to  irritation 
from  the  uterus  acting  reflexly  on  the  vasomotor  system  and  causing 
constriction  of  the  renal  vessels.  Numerous  other  views  have  been  put 
forth,  but  at  present  a  groundwork  of  facts  is  wanting. 

The  altered  condition  of  the  blood  probably  contributes  more 
to  the  establishment  of  the  oedematous  swellings,  especially  in 
the  upper  parts  of  the  body,  than  the  mechanical  pressure. 
The  blood,  in  pregnancy,  is  poor  in  red  corpuscles  and  more 
watery  than  natural — a  condition  highly  favorable  to  serous 
transudation,  and  to  the  production  of  anasarca  and  albuminous 
urine. 

The  expulsion  of  the  foetus  is,  as  has  been  stated,  commonly 
the  signal  for  the  disappearance  of  the  oedematous  swellings, 

1  Dr.  Dickinson,  in  his  work  on  Albuminuria,  describes  cases  of  the  albuminuria 
of  pregnancy  in  which  the  kidnej's  were  found  pale  and  fatty,  but  he  also  gives  a 
plate  representing  the  kidney  in  another  case,  where  venous  congestion  was  well 
marked. 


brigiit's  disease  and  pregnancy.  373 

and  the  restoration  of  the  urine  to  its  healthy  state;  but  in  a 
certain  number  of  cases  eclamptic  convulsions  break  out  about 
the  time  of  parturition,  and  of  these  about  30  per  cent,  prove 
fatal;  in  certain  other  cases  the  albuminuria  does  not  disapftear 
after  delivery,  but  persists,  with  or  without  dropsical  effusions, 
until  there  is  no  longer  any  doubt  that  genuine  and  confirmed 
Bright's  disease  has  been  established. 

There  has  been  much  dispute  as  to  the  exact  nature  of  the 
connection  between  the  events  here  enumerated  and  the  puer- 
peral state.  It  has  been  on  the  one  hand  alleged,  and  on  the 
other  hand  denied,  that  the  pregnant  state  is  an  effective  ex- 
citing cause  of  Bright's  disease;  it  has  also  been  both  alleged 
and  denied  that  puerperal  convulsions  are  of  renal  (uraemic) 
origin. 

There  can  be  no  doubt  that  many  of  the  cases  in  which  Bright's 
disease  coexists  with,  or  follows,  the  pregnant  state,  are  examples 
of  the  coincidence  of  two  mutually  independent  conditions. 
Pregnant  women  are,  of  course,  liable,  like  other  persons,  to 
contract  Bright's  disease  from  any  of  its  ordinary  causes ;  and, 
again,  women  who  are  already  the  subjects  of  Bright's  disease 
may  become  pregnant.  But  after  eliminating  the  cases  belong- 
ing to  these  two  categories,  there  are  still,  as  I  believe,  a  con- 
siderable number  in  which  Bright's  disease  has  been  really 
caused  by  pregnancy.  The  Registrar-General's  reports  furnish 
some  valuable  evidence  on  this  point.  In  the  five  years  1857-61, 
there  were  registered  6220  deaths  from  Bright's  disease.  Of 
these  3699  were  males,  and  2521  females — being  in  the  propor- 
tion of  68  females  to  every  100  males;  this  was  the  relative 
proportion  between  the  two  sexes  at  all  ages.  But  the  deaths 
of  women  from  Bright's  disease  during  the  child-bearing  years 
of  life  (from  twenty  to  forty-five)  far  exceeded  this  proportion — 
being  as  high  as  80  women  to  every  100  men.  After  the  age  of 
45,  the  proportion  of  deaths  from  Bright's  disease  sank  again 
to  59  women  for  every  100  men.  There  seems  no  other  con- 
clusion to  be  drawn  from  these  numbers,  than  that  the  puerperal 
state  is  a  prolific  cause  of  Bright's  disease. 

A  certain  number  of  pregnant  women  having  albuminuria 
(probably  about  one  in  ten)  are  affected  with  epileptiform  con- 
vulsions (or  eclampsia)  before,  during,  or  after  labor.^ 

It  is  a  question  of  considerable  interest  whether  puerperal 
eclampsia  is  due,  or  not,  to  uraemic  poisoning.  The  affirmative 
has  been  warmly  supported   by  Frerichs,   Braun,  Litzmann, 

^  The  liability  of  albuminuric  pregnant  women  to  eclampsia  is  estimated  at  a 
much  higher  rate  than  this  by  Blot,  Mej-er,  and  Devilliers  and  Eegnauld.  The 
united  statistics  of  these  observers  give  a  proportion  of  about  1  in  4.  Taking  all 
pregnancies  together — with  and  without  albuminuria — about  1  in  500  are  com- 
plicated with  eclampsia.     Braun  gives  the  proportion  as  1  in  545. 


374  CONGESTION    OF    THE    KIDNEYS. 

Wieger,  and  others ;  and  the  negative  by  Scanzoni,  Depaul, 
Rosenstein,  and  several  more. 

On  the  affirmative  side  it  has  been  shov^^n :  (1)  that  eclamptic 
fits  are  similar,  symptomatically,  to  ursemic  convulsions ;  (2)  that 
albumen  is  almost  invariably  present  in  the  urine  of  eclamptic 
patients;  and  that  in  several  cases  undoubted  evidence  of  or- 
ganic kidne}^  disease  has  been  found  after  death ;  (3)  that,  fre- 
quently, anasarca  of  the  upper  parts  of  the  body,  and  dryness 
of  the  skin,  coexist  with  albuminuria,  and  confirm  the  diagnosis 
of  Bright's  disease. 

On  the  opposite  side  it  is  alleged :  (1)  that  there  are  authentic 
instances  (apart  from  epilepsy,  apoplexy,  or  hysteria)  of  puer- 
peral eclampsia  without  albuminuria;^  (2)  that  anatomical  evi- 
dence of  Bright's  disease  has  only  been  found  in  a  minority  of 
the  cases ;  that  more  frequently  the  kidneys  have  only  been 
found  congested  without  any  organic  alterations  which  could 
be  identified  with  any  form  of  Bright's  disease ;  (3)  that  other 
causes  (than  Bright's  disease)  have  been  repeatedly  found  in  the 
bodies  of  persons  dying  of  puerperal  eclampsia,  namely,  oedema 
of  the  brain,  and  congestion  of  the  meninges,  which  probably 
were  not  without  concern  in  bringing  about  the  attacks. 

The  want  of  segregation  of  irrelevant  cases  prevents  the  pos- 
sibility of  a  clear  analysis  of  the  facts  adduced  in  this  dispute. 
But  it  is  evident  that  the  existence  of  well-attested  cases  of 
eclampsia  without  a  trace  of  albumen  in  the  urine,  is  fatal  to 
the  universality  of  the  ursemic  theory.  On  the  other  hand,  the 
not  infrequent  coexistence  of  undoubted  Bright's  disease,  leads 
strongly  to  the  conviction,  that,  in  many  cases,  the  convulsions 
are  truly  ursemic.  It  must  not,  however,  be  forgotten,  that 
pregnant  women  who  are  the  subjects  of  confirmed  Bright's 
disease  frequently  pass  through  labor  without  the  least  convul- 
sive disturbance. 

As  the  evidence  now  stands,  puerperal  eclampsia  cannot 
always  be  attributed  to  one  and  the  same  invariable  cause.  In 
some  instances,  the  convulsions  appear  to  be  essentially  of  a 
reflex  character,  arising  from  irritation  of  the  generative  organs, 
acting  on  a  nervous  system  in  a  state  of  exalted  sensibility.  It 
is  at  the  period  when  this  sensibility  attains  its  maximum, 
namely,  during  the  act  of  labor,  that  convulsions  usually  break 
forth.  But  it  is  likewise  about  the  same  period  that  the  pres- 
sure within  the  abdomen  becomes  most  intense,  and  the  stagna- 
tion in  the  renal  veins  and  interruption  to  the  secretion  of  urine 
most  complete.     When  the  act  of  birth  commences  there  are 

1  Among  other  examples,  the  followina;  may  be  referred  to:  Abeille,  loc.  cit., 
p.  607;  Kiedel,  Zeitschr.  f.  d.  Gehurtscheilk.,  1858,  p.  13;  Kossi,  ibid.,  1863, 
Bd.  ii.  S.  72.  See,  also,  Schrdder,  Ingerslev,  and  Lohlein,  quoted  by  Wagner, 
loc.  cit. 


PUERPERAL    ECLAMP.yiA.  375 

added  to  these  cauBes  of  disturbance,  violent  and  general  mus- 
cular contractions  causing  sutiusion  of  the  features  and  con- 
gestion of  the  cephalic  meninges.  Several  explosive  elements 
are  thus  brought  together  at  the  same  period  ;  and  it  is  scarcely 
to  be  wondered  at,  that  the  equilibrium  of  the  nervous  system 
should  be  thereby  occasionally  overset. 

The  recognition  of  two  or  more  categories  of  puerperal 
eclampsia,  is  of  much  importance  both  for  prognosis  and  treat- 
ment; and  the  want  of  some  rational  classification  of  the  cases 
is  doubtless  one  cause  of  the  discrepancies  in  the  experience  of 
different  observers  as  to  the  beneficial  effects  of  venesection  and 
other  plans  of  treatment. 

At  least  three  categories  seem  to  deserve  to  be  recognized,  viz., 
1.  Cases  depending  on  confirmed  and  chronic  Brighfs  disease.  In 
these  the  eclampsia  must  be  regarded  as  mainly  or  wholly  urse- 
mic;  the  ultimate  prognosis  is  lethal,  and  depletive  measures 
are  less  indicated  than  chloroform,  etc.  2.  Cases  depe:}iding  on 
'passive  congestion  of  the  kidneys,  or  on  a  condition  resembling,  if  not 
identical  loith,  acute  BrighVs  disease.  These  are  usually  primi- 
parse;  the  phenomena  are  probably  partly  ursemic,  and  partly 
reflex ;  the  prognosis  is  favorable,  were  the  fits  once  over ;  active 
depletive  measures  are  indicated.  3.  Cases  depending  on  reflected 
uterine  irritation  and  meningeal  congestion.  In  these  the  urine  is  not 
albuminous ;  the  prognosis  is  favorable,  were  the  fits  over ;  they 
call  for  active  depletory  measures. 

Something  remains  to  be  said  in  the  way  of  diagnostic  indica- 
tion, in  cases  of  pregnancy  complicated  with  albuminuria. 

The  urine  of  a  pregnant  woman  being  found  albuminous — 
how  shall  it  be  known,  whether  there  exists  confirmed  Bright's 
disease  or  only  a  temporary  disorder  which  will  harmlessly  sub- 
side after  parturition  ?  The  following  points  tell  strongly  for 
confirmed  Bright's  disease — an  abundant  flow  of  pale  urine  of 
low  density ;  presence  of  granular  or  fatty  casts  ,  a  considerable 
amount  of  albumen  and  yet  a  relaxed  state  of  the  abdomen  and 
tissues  generally;  anaemia;  a  markedly  hypertrophied  left  ven- 
tricle ;  anasarca  equally  distributed  (or  nearly  so)  over  the  whole 
body.  The  points  which,  on  the  other  hand,  tell  in  favor  of  con- 
gestion, or  of  acute  (and  curable)  Bright's  disease  are :  evident 
signs  of  severe  pressure  within  the  abdomen ;  the  patient  being 
a  primipara;  the  quantity  of  albumen  in  the  urine  appearing 
to  bear  a  proportion  to  the  existing  venous  congestion :  the 
urine  being  high-colored,  scanty,  and  dense ;  the  anasarca  being 
mostly,  or  altogether,  confined  to  the  lower  extremities ;  absence 
of  anaemia  and  cardiac  hypertrophy. 

By  attention  to  these  points  I  have  been  able,  in  the  cases 
which  have  fallen  under  my  observation,  to  frame  a  diagnosis 
which  the  event  has  justified. 


CHAPTER    II. 

BRIGHT' S  DISEASE. 
PEELIMINAEY   EEMAKKS. 

Cases  characterized  by  albuminuria  and  dropsy,  depending 
on  structural  changes  in  the  kidneys,  are  classed  together  under 
the  general  title  of  Bright's  disease. 

Several  different  pathological  states  are  doubtless  included 
under  this  designation ;  and  the  cases  present  considerable 
diversity,  not  only  in  the  acuteness  of  their  course  but  also  in 
their  modes  of  origin  and  symptoms.  Numerous  attempts  have 
been  made  to  divide  and  classify  the  various  conditions  of  the 
kidney  found  after  death  from  Bright's  disease ;  and  to  connect 
each  with  its  appropriate  clinical  history.  Hitherto  none  of 
these  attempts  has  obtained  general  assent;  and  a  regrettable 
confusion  of  nomenclature  has  been  added  to  the  inherent  in- 
tricacies of  the  subject.  Notwithstanding  the  diversities  just 
referred  to,  the  points  of  resemblance  between  the  several 
varieties  of  Bright's  disease  are  so  strong  and  so  numerous, 
that  they  form  an  easily  recognized  clinical  group.  This  re- 
semblance arises,  in  great  part,  from  the  circumstance  that  the 
structural  changes  in  the  kidneys,  various  as  they  may  be,  bring 
about  the  same  ultimate  results,  namely,  impoverishment  of  the 
blood  from  loss  of  albumen,  with  poisoning  of  it  from  retention 
within  the  body  of  the  excrementitious  matters  of  the  urine ; 
and  the  more  prominent  symptoms  in  Bright's  disease  arise 
from  this  changed  condition  of  the  blood,  rather  than  from  the 
direct  effects  of  the  structural  changes  in  the  kidneys. 

Opinions  are  divided,  in  the  first  place,  as  to  whether  there 
be  a  fundamental  unity  beneath  the  apparent  diversity;  in 
other  words,  whether  the  "  large,  smooth,  white  kidney,"  the 
"  small,  smooth  kidney,"  the  "  granular  uncontracted  kidney," 
and  the  "granular  contracted  kidney,"  are  successive  stages  of 
one  and  the  same  pathological  process,  or  represent  radically 
distinct  diseases. 

Dr.  Bright,  whose  researches  on  this  subject  have  made  his 
name  so  renowned  in  medical  science,  expresses  himself  quite 
doubtfully  on  this  point.  In  his  introductory  remarks  to  the 
twenty-three  cases  tirst   published  by  him,  in  1827,  he   says: 


PKELIMINARY    RKMAKKH.  377 

"  From  the  observations  which  I  have  mado,  I  have  boon  led  to 
believe  that  there  may  be  several  forms  of  disease  to  vvhicli  the 
kidney  becomes  liable  in  the  progress  of  dropsical  affections. 
I  have  even  thought  that  the  organic  derangements  which  have 
already  presented  themselves  to  my  notice,  will  authorize  the 
establishment  of  three  varieties,  if  not  of  three  completely  sepa- 
rate forms  of  diseased  structure."  But  toward  the  close  of  the 
same  remarks  he  observes:  "Although  I  hazard  a  conjecture 
as  to  the  existence  of  these  three  different  forms  of  disease,  I  am 
by  no  means  confident  of  the  correctness  of  this  view.  On  the 
contrary,  it  may  be  that  the  first  form  of  degeneracy  to  which 
I  refer  never  goes  much  beyond  the  first  stage;  and  that  all  the 
other  cases,  together  with  the  second  series  and  the  third,  are 
to  be  considered  only  as  modifications,  and  more  or  less  ad- 
vanced states  of  one  and  the  same  disease."  (Reports,  pp.  67 
and  69.) 

Soon  after  the  period  when  these  sentences  were  written,  a 
new  vantage  ground  for  the  study  of  renal  diseases  was  acquired 
by  the  researches  of  Mr.  Bowman,  which  threw  a  strong  light 
on  the  intricate  anatomy  of  the  kidney.  Histologists  of  emi- 
nence both  in  this  country  and  Germany — Busk,  Toynbee, 
Simon,  Henle,  Rokitansky,  Virchow — and  inquirers  who  have 
made  the  subject  a  special  study — Johnson,  Frerichs,  Bash  am, 
Dickinson,  Grainger  Stewart,  and  many  more — have  worked 
with  unexampled  perseverance  to  ascertain  the  nature  and 
arrange  the  varieties  of  the  morbid  processes  taking  place  in 
the  kidnej^s  in  Bright's  disease  ;  and  yet  the  doubt  which  pos- 
sessed the  mind  of  Bright  has  not  been  wholly  cleared  away. 

All  this  labor  has  not,  of  course,  been  thrown  away.  On  the 
contrary,  much  light  has  been  shed  on  the  pathology  of  the 
complaint ;  and  data  of  importance  have  been  obtained  for 
prognosis  and  treatment.  More  especially  the  examination  of 
the  organic  admixtures  of  the  urine — renal  epithelium  and  casts 
of  the  uriniferous  tubes — has  yielded  to  Dr.  Geo.  Johnson  re- 
sults of  the  highest  clinical  value,  which  claim  for  him  a  pre- 
eminent mention  in  this  field  of  pathology. 

Frerichs  considers  that  Bright's  disease  is  essentially  one, 
and  that  it  is  of  an  inflammatory  nature.  He  divides  the  ana- 
tomical changes  in  the  kidneys  into  three  forms,  which  he  re- 
gards as  stages  of  the  same  fundamental  process,  namely  :   • 

1.  The  stage  of  hypersemia  and  commencing  exudation. 

2.  The  stage  of  exudation  and  commencing  change  of  the 
exudation. 

3.  The  stage  of  degeneration  and  atrophy. 

Dr.  Johnson,  on  the  other  hand,  recognizes  several  distinct 
processes  under  the  common  heading  of  Bright's  disease — but 
chiefly  two,  and  both  of  an  inflammatory  nature — one  charac- 


378  bright's  disease. 

terized  by  a  shedding  and  destruction  of  the  epithelial  lining  of 
the  uriniferous  tubes  {desquamative  nephritis),  and  one  without 
such  desquamation,  and  affecting  the  intertubular  structures  of 
the  organ  (non-desquamative  nephritis).  He  also  gives  a  separate 
place  to  "  fatty  degeneration  "  and  "  waxy  degeneration  "  of  the 
kidney. 

Dr.  Dickinson  divides  Bright's  disease  into  three  main  varie- 
ties. 1.  Tubal  nephritis,  in  which  the  uriniferous  tubes  are  the 
seat  of  an  inflammatory  action.  This  he  subdivides  into  an 
acute  and  a  chronic  form.  2.  Granular  degeneration,  in  which 
there  is  increase  and  subsequent  contraction  of  the  intertubular 
matrix  of  the  kidney.  3.  Depurative  disease,  which  is  the  name 
he  gives  to  amyloid  or  waxy  infiltration  of  the  kidneys. 

Dr.  Grainger  Stewart  suggests  the  name  "  Bright's  Diseases  " 
as  more  truly  descriptive  than  the  old  designation  "  Bright's 
Disease."     He  classifies  the  cases  as  follows  : 

1.  The  inflammatory  form,  of  which  there  are  three  stages — 

a.  That  of  inflammation. 

b.  That  of  fatty  transformation. 

c.  That  of  atrophy. 

2.  The  waxy  or  amyloid  form,  of  which  also  there  are  three 
stages — 

a.  That  of  degeneration  of  the  vessels. 

b.  That  of  secondary  changes  in  the  tubes. 

c.  That  of  atrophy. 

3.  T'he  cirrhotic,  contracting,  or  gouty  form. 

In  addition  to  these  he  described  two  mixed  types,  in  which 
in  the  one  case  the  waxy  form,  and  in  the  other  the  cirrhotic 
form,  is  combined  with  the  inflammatory  form. 

It  would  lead  me  too  far  to  discuss  the  merits  of  these  and 
the  many  other  classifications  which  have  been  put  forth.  I 
content  myself  with  simply  indicating  the  more  important  ones. 
In  the  following  pages  the  subject  wnll  be  treated  from  a  clinical, 
rather  than  an  anatomical,  point  of  view,  and  the  cases  will  be 
classified  under  the  two  main  heads  of  acute  and  chronic  Bright's 
disease.  The  former  embraces  a  compact  and  universally  recog- 
nized group,  which  formerly  w^ent  under  the  designation  of 
"inflammatory  dropsy."  It  corresponds  to  the  acute  desquama- 
tive nephritis  of  Johnson,  to  the  first  stage  of  Frerichs,  and  to 
the  acute  tubular  disease  of  Dickinson,  The  latter  includes  the 
protracted  cases,  which  either  have  lapsed  into  a  chronic  state 
from  the  acute  form,  or,  which  is  far  more  frequent,  have  been 
chronic  from  the  beginning.  Three  types  of  chronic  Bright's 
disease  will  be  recognized.  1.  Cases  which  have  lapsed  from 
the  acute  state  (kidney  smooth,  white,  generally  large,  excep- 
tionally dwindled).  2.  Cases  which  have  been  chronic  from 
the  beginning   (kidney  granular,  red,   contracting).     3.  Cases 


GENERAL    ETIOLOGY.  379 

associated  with  waxy  or  lardaceous  (so-called  amyloid)  degenera- 
tion of  the  kidneys. 

The  presence  of  fat  in  the  renal  substance,  and  in  the  ci)ithe- 
lium  of  the  tubes,  is  not  special  to  any  one  type  of  renal  degen- 
eration; but  is  found  associated  with  anatomical  changes  of  the 
most  varied  kinds  :  it  has  therefore  no  claim  to  a  separate  con- 
sideration. 


GENERAL  ETIOLOGY  OF  BRIGHT'S  DISEASE. 

The  special  etiology  of  the  several  types  of  Bright's  disease 
will  be  separately  considered  in  the  twe  following  chapters,  but 
it  will  be  convenient  in  this  place  to  consider  some  of  the  points 
bearing  on  the  etiology  of  Bright's  disease  as  a  whole. 

The  want  of  uniformity  in  our  nomenclature  of  organic  dis- 
eases of  the  kidneys  has  considerably  lessened  the  value  of  the 
returns  of  the  Begistrar-General  in  this  field  of  pathology. 
Cases  registered  on  the  certificate  of  death  as  "  Bright's  dis- 
ease"  are  entered  in  these  returns  as  "nephria;"  but  it  is 
evident  that  the  larger  number,  even  of  the  cases  recognized  as 
Bright's  disease  during  life,  are  not  so  registered,  but  are 
classified  under  the  heads  "  nephritis  "  and  "  kidney  disease." 
To  obtain  some  idea  of  the  prevalence  of  Bright's  disease,  let 
us  take  the  numbers  under  these  three  designations.  There 
were  registered  in  England  and  Wales,  in  1868  : 

2076  deaths  from  "  nephria," 

495  deaths  from  "  nephritis," 
283(3  deaths  from  "  kidney  disease," 

— making  a  total  of  5407.  This  yields  only  a  proportion  of  1.1 
•per  cent,  of  the  total  deaths  from  all  causes — a  number  which 
is  probably  considerably  below  the  true  proportionate  mortality 
from  Bright's  disease.  Without  admitting,  with  Mr.  Simon, 
that  two-thirds  of  the  cases  of  Bright's  disease  run  a  latent  or 
undiscovered  course,  it  must  be  allowed  that  a  very  large 
number  are  overlooked  in  these  returns,  and  are  probably  to  be 
found  among  the  6284  entered  as  "  dropsy,"  or  among  those 
entered  under  "  convulsions,"  "  pneumonia,"  and  other  head- 
ings.^ 

Bright's  disease  is  about  one-third  more  common  among  men 
than  women  (1215  men  to  861  females).      The  excess  of  deaths 

^  It  is  evident,  however,  that  Bright's  disease  is  gradually  becoming  better 
known  in  this  country,  and  more  frequently  identified.  In  1852,  only  570  deaths 
were  entered  under  "Nephria."  In  each  successive  j^ear  the  number  rose,  quite 
out  of  all  proportion  to  the  increase  of  the  population,  until  in  1861  it  reached 
1148,  nearly  thrice  as  many  as  in  1852 ;  and  in  1868  it  reached  2076,  nearly  four 
times  as  many  as  in  1852.  Correspondingly,  the  entries  under  "  dropsy  "  dimin^ 
ished,  from  9788  to  7301,  and  to  6284  for  the  same  three  vears. 


380 


bright's  disease. 


among  males,  although  present  at  every  age,  is  not  equal  at  the 
different  periods  of  life  :  it  is  most  marked  between  the  ages  of 
forty-iive  and  sixty-five. 

The  mortality  from  Bright's  disease  shows  a  progressive  in- 
crease from  childhood  up  to  about  the  age  of  50 ;  in  the  succeed- 
ing 20  years  the  mortality  continues  steady,  at  a  somewhat 
lower,  but  still  high,  rate;  the  next  decade  shows  a  decided 
diminution  as  regards  Bright's  disease,  though  the  general  mor- 
tality at  this  epoch  is  at  its  highest  point.  These  tacts  are  ex- 
hibited in  the  following  table: 

Table  showhig  the  number  of  deaths  registered  as  "  Nephria  "  {Bright's  disease) 
in  England  and  Wales  in  1868,  at  the  different  periods  of  life: 


Under 

5 
yrs. 

5-15 
yrs. 

15-25 
yrs. 

25-35 
yrs. 

35-45 
yrs. 

45-55 
yrs. 

55-65 
yrs. 

65-75 
yrs. 

75  years 

and 
upwards. 

Total 

at 

all  ages. 

Males    . 
Females 

41 
34 

60 
39 

87 
68 

157 

133 

216 
160 

247 

147 

225 
148 

133 

97 

49 
35 

1215 
861 

Both  sexes     . 

75 

99 

155 

290 

376 

394 

373 

230 

84 

2076 

That  complex  of  impressions  which  is  familiarly  known  as 
taking  cold  is  the  common  cause  of  Bright's  disease  in  its  acute 
form.  Cold,  operating  more  slowly  and  continuously,  also  con- 
stitutes a  prolific  source  of  chronic  Bright's  disease.  Persons 
whose  occupation  exposes  them  to  cold,  wet,  and  the  inclemen- 
cies of  the  seasons,  without  adequate  protection — those  who 
work  in  hot  workshops,  are  in  the  habit  of  going  to  cool  their 
reeking  bodies  in  the  open  air — the  indigent  classes,  who  dwell 
in  damp  cellars,  insufiiciently  clad  and  ill-fed,  amid  dirt  and 
squalor,  furnish  a  large  quota  of  victims  to  this  disease. 

Dr.  Johnson  is  at  especial  pains  to  explain  the  modus  operandi 
of  this  frequent  cause  of  renal  disease.  He  contends  that  the 
defective  action  of  the  skin  causes  certain  deleterious  matters  to 
accumulate  in  the  blood,  and  that  the  burden  of  their  elimina- 
tion is  thrown  upon  the  kidneys,  which  receive  injury  thereby. 
It  is  impossible  to  accept  this  view  without  great  limitation, 
seeing  that  suppressed  cutaneous  transpiration  ushers  in  a  multi- 
tude of  inflammatory  and  febrile  conditions,  without  provoking 
renal  disease.  When  a  person  "  takes  cold,"  it  is  a  fact  that  the 
secretion  of  the  skin  is  very  much  diminished  or  altogether  sup- 
pressed: but  it  is  not  possible  to  predicate  on  what  organ  the 
injurious  impression  will  ultimately  settle — whether  on  the 
bronchial  tubes,  the  pleura,  the  lung  tissue,  the  kidneys,  or  some 
other  organ  or  part  of  the  body;  so  that  it  cannot  be  maintained 
that  there  is  any  special  relation  between  suppressed  cutaneous 
secretion  and  the  genesis  of  renal  disease. 


GENERAL    ETIOLOGY.  y81 

2^he  abuse  of  spirituous  liquors  ranks  high  U8  a  doterrnining 
-cause  of  Bright's  disease.  Christisori  estimates  the  proportion 
due  to  this  cause,  in  Edinburgh,  as  three-fourths  or  four-iifths 
of  all  the  cases;  and  he  justly  remarks  that  it  is  not  hal>itual 
drunkards  only  who  show  this  tendency  to  renal  disease,  but 
dram-drinkers,  who  are  in  the  constant  practice  of  using  ardent 
spirits  several  times  in  the  course  of  the  day,  without  becoming 
actually  intoxicated. "^ 

Malt  liquors — though  far  less  pernicious  than  spirits — are  not 
without  influence  to  produce  Bright's  disease  when  largely  in- 
dulged in.  In  a  journeyman  baker,  under  my  care  at  the  Infir- 
mary, the  disease  was  clearly  traced  to  the  habit  of  fuddling 
himself  with  beer  from  Saturday  evening  to  Monday  morning, 
which  the  patient  had  followed  for  several  years. 

Very  frequently,  intemperate  habits  go  hand  in  hand  with  a 
grimy  skin  and  exposed  occupation  ;  and  the  subjects  of  Bright's 
disease  are  found  disproportionately  numerous  among  laborers, 
well-sinkers,  cabmen,  carters,  hawkers,  glass-blowers,  smelters, 
and  puddlers. 

A  large  number  of  cases  arise  in  connection  with  some  C07i- 
stitutional  vice,  more  especially  tuberculosis  or  struma,  and  chronic 
lead  poisoning.  Among  the  easier  classes,  gout  and  constitu- 
tional syphilis  are  prominent  antecedents. 

It  seems  now  to  be  fully  attested  that  ague  may  cause  Bright's 
disease  in  its  various  forms.^ 

Chronic  affections  of  the  lower  urinary  passages  (cystitis,  stricture, 
etc.)  frequently  lay  the  foundations  of  renal  disease.  In  a  boy 
of  seven,  who  died  in  the  Royal  Infirmary,  a  small  stone  no 
larger  than  an  almond  was  found  lodged  near  the  neck  of  the 
bladder.  Repeated  sounding  had  failed  to  detect  it  during  life; 
operation  was  consequently  not  performed.  For  some  weeks 
before  death,  general  anasarca  had  shown  itself.  The  kidneys 
were  found  wasted  to  an  extreme  degree;  the  cortical  substance 
was  reduced  to  a  thin  edge  no  thicker  than  a  shilling;  the  pel- 
vis of  the  kidney  and  the  ureters  were  dilated,  and  their  lining- 
membrane  thickened  and  bathed  in  pus.  In  cases  of  this  class 
there  is  a  double  influence  tending  to  produce  renal  degenera- 
tion, namely,  the  long-continued  exhausting  suppuration  and 
direct  transmission  of  the  inflammatory  process  by  continuity 
of  tissue. 

1  Dr.  Dickinson,  in  his  work  on  Albuminuria,  has,  in  an  elaborate  chapter, 
called  in  question  the  efficiency  of  intemperance  as  a  frequent  cause  of  chronic 
Bright's  disease.  I  have  examined  his  statements  at  length  in  a  paper  in  the 
Brit.  Med.  Journ.  for  Nov.  4,  1871, — and  have  shown,  conclusively  as  I  believe, 
that  the  arguments  he  advances  are  inadequate  to  shake  the  old  opinion. 

2  A  full  account  of  the  anatomical  changes  produced  in  the  kidney  by  ague  will 
be  found  in  a  paper  by  Kiener  and  Kelsch,  Archives  des  Physiologie,'Feb.  18821 


382  BRIGHT'S    l^ISEASE. 

The  use  of  mercurj^,  which  Wells  and  Blackall  believed  capa- 
ble of  producing  albuminuria  and  renal  mischief,  has  not  been 
found  by  observers  of  wider  experience  to  have  this  effect. 
Raver  and  Desir,  out  of  forty  cases  treated  with  mercury  at  the 
Hopital  des  Yeneriens,  only  found  a  slight  quantity  of  albumen 
in  two — in  both  of  which  its  presence  was  accounted  for  by  the 
existence  of  pus  in  the  urine.  Rayer  further  observes  that  he 
had  for  years  used  a  multitude  of  mercurial  preparations  in  the 
treatment  of  various  diseases  without  ever  having  observed  the 
production  of  dropsy.  He  also  states  that  he  had  treated  a 
large  number  of  gilders  affected  with  mercurial  trembling,  and 
that  he  had  not  seen  a  single  case  of  dropsy  with  coagulable 
urine  supervene  during  or  after  this  trembling  (see,  also,  p.  196, 
note), 

A  certain  number  of  cases  of  chronic  Bright's  disease  present 
themselves,  in  which  the  most  searching  analysis  fails  to  indi- 
cate the  exciting  cause  of  the  disorder.  In  some  of  these  the 
renal  affection  is  only  a  part  manifestation  of  some  widespread 
cachexy,  as  an  example  (M.  H.)  to  be  related  in  Chap.  IV.,  in 
which  fatty  degeneration  coexisted  in  the  heart,  great  vessels, 
brain,  and  kidneys. 


CHAPTER    III. 

ACUTE  BRIGHT' S  DISEASE. 

Synonyms — Inflammatory  Dropsy;  Diffuse  Nephritis;  Acute  Desquamative 
Nephritis  (Johnson);  Acute  Tubal  Nephritis  (Dickinson). 

Anatomical  Characters. — The  kidneys  are  always  more  or 
less  enlarged — sometimes  to  twice  their  natural  size;  their  sur- 
face is  smooth  ;  the  capsule  thin,  transparent,  and  easily  stripped 
off';  their  color  varies;  it  is  generally  a  deep  dusky  red;  but 
sometimes  a  light  fawn,  almost  white;  in  other  cases  it  is 
mottled  red  and  white.  The  superficial  veins  are  larger  and 
more  distinct  than  natural.  When  the  kidney  is  cut  open  the 
cortical  substance  is  found  to  be  increased  very  much  out  of 
proportion  to  the  pyramidal.  The  red  congested  kidney  exudes 
a  bloody  sanies  abundantly  from  the  cut  surface;  a  number  of 
hemorrhagic  spots  may  be  generally  seen  scattered  through  the 
cortex  or  beneath  the  capsule.  The  surface  of  the  section  is 
dusky  red,  and  studded  with  minute  darker-red  points,  which  are 
the  engorged  Malpighian  corpuscles.  The  'pale  and  the  mottled 
kidneys  present  a  contrast  of  color  between  the  cortex  and  the 
pyramids.  The  latter  appear  unnaturally  red,  and  from  their 
bases  radiating  lines  of  red  spread,  fan-like,  into  the  cortical 
substance.  The  cortical  portion  is  smooth  and  white,  or  yellow- 
ish-white, and  spotted  like  ivory. 

Under  the  microscope  almost  all  parts  of  the  kidney  may  be 
found  affected,  but  in  varying  proportions  in  different  cases. 
Usually  the  chief  alteration  is  situated  in  the  epithelial  contents 
of  the  convoluted  tubes.  The  diameters  of  these  are  increased, 
and  in  extreme  examples  to  twice  or  even  thrice  their  normal 
measurement.  The  epithelial  cells  are  also  increased  in  size, 
they  cannot  easily  be  distinguished  one  from  another,  and  their 
free  extremities  are  rounded.  The  striation  of  the  protopilasm 
at  the  base  of  each  cell  is  no  longer  seen,  but  instead  an  ex- 
tremely granular  condition  is  observed,  which  in  advanced  cases 
gives  place  to  a  collection  of  fat  globules.  The  nuclei  of  the 
cells  may  be  hidden  by  the  swollen  protoplasm  ;  when  seen, 
they  are  found  to  be  greatly  proliferated,  and  a  division  of  the 
cell  substance  taking  place  round  each  nucleus,  we  have  a  multi- 


384  ACUTE  bright's  disease. 

plication  of  the  cells.^  Cornil  has  described  in  the  cell-proto- 
plasm certain  hyaline  globules,  which  apparently  proceed  from 
the  base  to  the  free  margin  and  discharge  themselves  into  the 
lumen  of  the  tubule.  The  epithelial  cells  may  be  so  hypertro- 
phied  as  to  fill  completely  the  lumen  of  the  tubule.  More 
commonly  the  lumen  is  occupied  either  by  accumulations  of 
cells,  consisting  of  detached  epithelium  and  leucocytes,  or  by  a 
fibrinous  exudation,  which  in  the  higher  tubules  assumes  a  net 
or  star-like  arrangement;  but  lower  down,  and  especially  in  the 
straight  tubes,  it  forms  glossy  cylinders  of  various  size,  accord- 
ing as  the  tubes  have  preserved  or  have  shed  their  proper 
lining.  In  the  straight  tubes  the  epithelium  gives  evidence  of 
similar  changes,  but  to  a  much  less  intense  degree.  Their  larger 
bore  and  direct  course  favor  the  escape  of  the  detached  epithe- 
lium, so  that  some  of  them  are  partially  or  wholly  denuded. 
In  the  later  stages  the  cells  of  the  convoluted  tubules  also  break 
down,  and  Klein  has  described,  in  scarlatinal  kidneys,  a  deposit 
of  lime  salts  in  the  cells.^ 

The  interstitial  tissue  of  the  kidney  may  be  unaffected,  but 
often  shows  an  infiltration  of  leucocytes,  even  at  a  compara- 
tively early  period.  These  are  situated  most  commonly  round 
the  glomeruli  constituting  the  so-called  "  pericapsular  "  neph- 
ritis; but  later  on  cell-accumulation  is  found  also  between  the 
tubules  and  around  the  arteries. 

The  arteries  and  capillaries  are  distended  with  blood-cor- 
puscles, and  more  or  less  extensive  rupture  of  the  capillaries 
takes  place.  The  hemorrhages  sometimes  form  a  marked  fea- 
ture. Masses  of  red  blood-corpuscles  are  then  found  lying  in 
the  intertubular  tissue,  distending  the  tubules  themselves,  and 
occasionally  lying  between  the  epithelial  cells  or  embedded  in 
the  cell-protoplasm.  Klein  has  described  a  hyaline  thickening 
of  the  intima  in  the  arteries,  and  more  especially  in  the  afferent 
vessel  of  the  glomerulus.  The  nuclei  of  the  endothelium  and 
of  the  muscular  fibres  he  also  found  in  a  state  of  proliferation. 

The  morbid  process  seems  to  consist  essentially  in  a  catarrhal 
condition  of  the  uriniferous  tubes,  with  a  prodigious  swelling 
and  proliferation  of  their  epithelial  elements.  At  the  first,  there 
is  an  inflammatory  congestion  of  the  organs  with  rapid  swelling 

1  A  few  observers,  and  most  recently  Cornil  and  Brault,  have  denied  that  such 
proliferation  of  the  epithelium  takes  place,  when  the  inflammation  attacks  a 
previously  healthy  kidney. 

2  Litten  also  has  described  calcification  of  the  cells.  See  Yirch.  Archiv,  Bd. 
83,  S.  508. 

3  Many  of  the  appearances  described  above  have  been  made  use  of  by  some 
authors  as  the  bases  of  a  classification.  Thus,  Wagner  describes  four  forms  of 
acute  Bright's  disease.  1.  The  hemorrhagic-catarrhal.  2.  The  hemorrhagic- 
catarrhal  with  interstitial  change.  3.  The  acute  large  pale  kidney.  4.  The 
acute  lymphomatous  kidney.  It  has  not  been  thought  advisable  in  a  work  like 
the  present  to  attempt  any  classification  of  the  anatomical  features. 


ANATOMICAL    ClI  A  K  A  CT  E  US  .  liH^ 

and  rupture  of  the  capillaries.  On  that  follovvH  incroaHed  pro- 
duction of  epithelial  cells;  these  rnuhi[)ly,  choke  up  and  distend 
the  uriniferous  tubes,  thereby  conn)reHsinf^  the  renal  ca[)illaries 
and  impeding  the  circulation  through  them. 

When  this  proliferation  has  reached  a  certain  degree,  the 
kidneys,  which  before  were  of  a  dusky  red,  become  pale  or  mot- 
tled— not  so  much  from  an  actual  deficiency  of  blood  in  the 
organs,  but  rather,  as  Dickinson  explains,  from  the  white  color 
of  the  masses  of  epithelium  overpowering  the  natural  red  of 
the  parts. 

The  choking-up  of  the  tubes  with  their  own  epithelium  neces- 
sarily impedes  the  depurating  functions  of  the  kidneys,  and  the 
blood  is  poisoned  with  excrementitious  matters.  The  urine 
becomes  scanty  in  amount,  and  deiicient  in  its  proper  constitu- 
ents ;  it  carries  with  it,  as  it  percolates  the  diseased  ducts,  loose 
epithelium,  blood,  and  fibrinous  exudation,  or  detaches  whole 
tracts  of  the  lining,  all  of  which  objects  form  an  abundant 
grumous  sediment  in  the  urine. 

How  soon  the  change  from  red  to  white  takes  place,  depends 
on  the  rapidity  of  the  multiplication  of  the  epithelial  cells.  I 
have  seen  the  bloodless  condition  reach  an  extreme  degree  in 
six  weeks.  Dr.  Dickinson  states  that  it  may  occur  within  four 
days. 

During  recent  years  the  attention  of  pathologists,  and  also  of 
clinical  observers,  has  been  turned  to  the  changes  undergone  bj- 
the  glomeruli  in  certain  cases  of  acute  and  subacute  Bright's 
disease.  When  the  conditions  described  above  are  present,  the 
glomeruli  are  seen  on  the  cut  surface  of  the  kidney,  as  red 
points;  while  under  the  microscope,  the  capillaries  of  the  Mal- 
pighian  tuft  are  found  injected,  and  the  space  between  the  tuft 
and  the  capsule  filled  with  red  blood-corpuscles.  In  the  cases 
of  so-called  glomerulo-nephritis  the  glomeruli  appear  as  pale 
points  on  tlie  section ;  and  extensive  inflammatory  changes  are 
found  in  them,  causing  almost  total  abolition  of  their  secreting 
power,  while  in  the  remainder  of  the  kidney  little  or  no  change 
may  be  seen.  The  results  of  different  observers  show  consider- 
able variance  with  regard  to  the  exact  changes  found  in  the 
Malpighian  corpuscle,  but  they  may  briefly  be  stated  as  follows  : 

Most  frequently  an  accumulation  of  cells  is  seen  between  the 
capsule  of  Bowman  and  the  glomerular  tuft.  These  cells  con- 
sist of  a  few  leucocytes  escaped  from  the  vessels,  but  for  the 
main  part,  of  cells  resulting  from  a  proliferation  of  the  epithe- 
lial lining  of  Bowman's  capsule.  Proliferation  has  also  been 
observed  in  the  thin  layer  of  epithelium  covering  the  tuft  and 
dipping  between  its  divisions,  and  doubtless  this  contributes  to 
the  cell  accumulation  in  the  glomerular  cavity.     My  colleague, 

2o 


386  ACUTE  bright's  disease. 

Dr.  Leeeh,^  has  described  proliferation  of  both  these  layers  in  a 
case  under  his  observation,  and  he  was  able  also  to  trace  the 
development  of  the  cells  into  a  mass  of  fully  formed  iibrous 
tissue  tilling  up  the  glomerular  space.  The  glomerular  tuft  is 
compressed  by  the  new  growth,  and  the  circulation  through  it  is 
stopped.  Hence,  its  pale  appearance  when  a  section  of  the  kid- 
ney is  made.  But  apart  from  any  exudation  between  the  tuft 
and  the  capsule,  the  circulation  through  the  glomerulus  may  be 
interfered  with  by  changes  in  the  tuft  itself.  These  changes  are 
generally  evident  from  the  great  increase  in  the  number  of 
nuclei  in  the  tuft.  The  numerous  nuclei  may  in  part  be  due  to  a 
proliferation  of  those  portions  of  the  epithelial  covering  of  the  tuft 
which  dip  down  between  its  several  divisions.  They  may  also  be 
the  nuclei  of  leucocytes  escaped  from  the  vessels.  Ivlebs  believed 
that  they  were  due  to  inflammatory  proliferation  of  the  connec- 
tive-tissue cells  binding  together  the  divisions  of  the  tuft.  This 
view  has  received  but  little  support,  and,  indeed,  the  existence  of 
connective  tissue  in  the  normal  tuft  is  denied.  Another  source 
of  the  numerous  nuclei  has  been  found  in  a  proliferation  of  the 
nuclei  of  the  capillaries  themselves.  Klein  has  shown  that  the 
capillary  walls  may  be  swollen  and  show  the  same  hyaline  change 
he  has  described  in  the  afferent  artery  of  the  glomerulus.  Fried- 
lander,  too,  has  described  changes  in  the  interior  of  the  capillaries 
of  the  tuft.  In  his  cases  the  circulation  through  the  tuft  was 
stopped,  not  by  pressure  from  without,  for  the  vessels  of  the  tuft 
were  even  larger  than  normal ;  but  by  blocking  of  the  capil- 
laries with  a  granular  mass  containing  nuclei,  and  produced,  as 
he  thinks,  by  a  thickening  of  the  capillary  wall.^ 

In  the  acute  nephritis  which  accompanies  or  follows  the  infec- 
tious diseases,  groups  of  microorganisms  have  been  seen  in  the 
kidney.  They  may  be  situated  in  the  bloodvessels,  causing  a 
thrombosis;  or  they  may  be  seen  in  the  urinary  tubules,  and 
within  the  epithelial  cells. 

Course  and  Symptoms. — The  invasion  of  the  disease  is  com- 
monly abrupt,  and  traceable  to  some  definite  cause.  A  person 
takes  cold,  or  falls  into  a  fit  of  intemperance,  and  next  morn- 
ing, or  in  two  or  three  days,  the  face  begins  to  swell,  then  the 
hands  and  bod}^  generally.  In  another  large  class  of  cases  the 
disease   breaks   out   daring   convalescence   from   scarlet  fever 

1  On  Glomerulo-nephrilis.     Brit.  Med.  Journal,  1881,  i.  p.  994. 

2  The  principal  works  on  Glomerulo-nephritis  are  the  following  : 

Klein,  Keports  to  the  Privy  Council,  1876,  p.  39.  Greenfield  (Atlas  of  Pa- 
thology, Syden.  Soc).  Waller,  Journal  of  Auat.  and  Phys.,  vol.  xiv.  p.  432. 
Leech,  Brit.  Med.  Journ.,  1881,  vol.  i.  p.  994. 

Klebs,  Handb.  d.  Path.  Anat.,  vol.  i.  p.  645.  Langhans,  Virch.  Arch.,  vol. 
Ixxvi.  p.  85.  Litten,  Charite  Annalen,  vol.  iv.  p.  30.  Priedlander,  Fortschr.  d. 
Medicin,  vol.  i.  No.  3. 


COURSE    AND    8YM]'T0MS.  887 

or — much  less  frequently — some  other  febrile  or  zymotic  com- 
plaint. 

Acute  Bright's  disease  is  usually  ushered  in  with  chilliness 
or  shivering,  headache,  nausea,  vomiting,  pains  in  the  back 
and  limbs,  arrest  of  the  cutaneous  perspiration  and  oppression 
in  the  chest. 

Dr.  Mahomed  has  made  important  observations  on  a  pre-albuminuric 
stage  of  Bright's  disease  following  scarlatina.  He  states  that  in  the 
desquamative  stage  of  scarlet  fever,  certain  symptoms  arise  which  are 
premonitory  of  the  appearance  of  albumen  in  the  urine,  namely,  high 
tension  of  the  arterial  system  as  measured  by  the  sphygraograph,  and 
transudation  into  the  urine  of  the  blood-crystalloids  as  tested  by  guai- 
acum  and  ozonic  ether.  The  almost  universal  forerunner  and  probable 
cause  of  these  symptoms,  he  says,  is  constipation.  One  day  passed  with- 
out an  action  of  the  bowels  is  sufficient  to  give  rise  to  them.  If  a  sharp 
purgative  be  administered  these  symptoms  pass  away ;  if  not,  they  are 
succeeded  by  the  usual  signs  of  severe  renal  disturbance. 

"When  fairly  established,  the  symptoms  are  exceedingly  dis- 
tinctive. The  countenance  is  pale  and  puffy,  with  a  heavy 
stupid  expression  ;  the  limbs  and  trunk  are  anasarcous.  The 
cedematous  parts  are  resistant  on  pressure,  and  pit  little  or  none. 
More  or  less  effusion  takes  place  into  the  serous  cavities,  especially 
the  pleura  and  peritoneum. 

There  is  a  general  febrile  movement;  the  pulse  is  hard,  full, 
and  of  high  tension,  the  appetite  lost,  thirst  excessive;  the  skin 
is  dry,  and  the  whole  surface  blanched  and  tumefied.  An  un- 
easiness or  dull  pain  is  felt  in  the  loins,  and  the  renal  regions 
are  tender  on  pressure. 

The  urine  is  of  a  smoky  or  dusky  hue — in  some  instances 
dark  brown  like  porter — from  the  presence  of  altered  blood. 
On  standing,  it  deposits  a  copious,  flocculent,  dirty-brown  or 
chocolate  sediment,  like  the  settling  from  beef-tea.  It  is  very 
albuminous;  it  may  even  become  quite  solid  on  boiling.  The 
specific  gravity,  in  the  stage  of  increment,  is  usually  above 
1020,  often  much  higher,  mounting  sometimes  to  1030,  and  in 
one  instance  which  occurred  to  me  even  to  1065.  When  of 
high  density,  the  urine  is  proportionally  scanty;  it  may  not 
exceed  12  or  18  ounces  in  the  twenty-four  hours ;  in  extreme 
cases  it  may  sink  to  4  or  6  ounces,  or  be,  for  two  or  three  days, 
altogether  suppressed.  The  calls  to  void  it  are  more  frequent 
than  in  health,  especially  at  night  and  in  the  recumbent  posture; 
the  patient  has  to  get  up  three  or  four  times  in  the  course  of  the 
night  to  empty  the  bladder.  The  urine  is  generally  acid,  and 
surcharged  with  pigment;  it  often  deposits  the  amorphous 
urates.      Very   rarely   it  is  alkaline  from  fixed   alkali.      The 


388 


ACUTE    BRIGHT'S    DISEASE. 


natural  urinous  odor  is  lost;  it  has  a  faint  unpleasant  smell, 
which  has  been  compared  to  that  of  the  washings  of  flesh. 

The  deposit  when  examined  microscopically  (see  Fig.  50)  is 
found  to  consist  of  blood-corpuscles,  loose  renal  epithelium,  free 
nuclei  of  these,  tube-casts,  shapeless  masses  of  coagulated 
fibrine,  and  the  broken  debris  of  all  these  structures. 

There  are  also  generally  found  epithelial  cells  from  the  pelvis 
of  the  kidney  and  the  bladder. 

The  renal  epithelia  vary  a  good  deal  in  their  appearance. 
Sometimes  they  look  almost  natural,  only  somewhat  swollen 
and  opaque.  More  frequently  they  are  much  broken  down ; 
their  nuclei  are  set  free,  or  are  only  invested  in  part  by  the 
granular  cell-contents  which  naturally  surround  them.  The 
disintegrated  epithelium  forms  an  amorphous  dark  granular 

Fig.  50. 


Transparent,  granular,  blood  and  epithelial  casts  from  a  case  of  acute  Bright's  disease ; 
free  renal  epithelium  ;  and  blood  disks. 

debris  scattered  over  the  field.  When  very  abundant,  the  epithe- 
lium communicates  a  milky  appearance  to  the  urine.  The  free 
nuclei  greatly  resemble  red  blood-disks  both  in  shape  and  size, 
but  they  are  devoid  of  the  biconcave  figure,  and  refract  light 
more  strongly.  A  solution  of  magenta  tints  them  of  a  deep 
carbuncle-red.  The  free  blood  disks  are  frequently  distorted. 
When  the  urine  is  of  high  density,  they  are  shrunken,  and 
often  puckered  at  the  margins ;  on  the  other  hand,  when  the 
urine  is  of  a  lower  density,  1017  and  under,  they  expand,  lose 
their  central  depressions,  and  eventually  burst,  and  cease  to  be 
recognizable. 


COURSE    AND    SYMPTOMS.  389 

The  tube-casts  are  al)uiidant,  and  of  varied  size  and  appear- 
ance. The  most  common  are  of  "  medium  "  size,  transjiarent, 
beset  with  epithelial  cells  or  blood  disks.  Mixed  with  these  may 
be  some  "  very  large  "  and  some  "  very  small  "  hyaline  casts, 
together  with  opaque  granular  casts  (Fig.  50), 

Specks  of  oil  are  generally  altogether  absent ;  sometimes, 
however,  a  few  small  ones  are  seen  either  on  the  casts  or  within 
the  epithelia;  but  their  number  is  always  quite  insignificant  in 
the  early  stages  of  the  disease. 

The  proportion  of  albumen  in  the  urine  during  the  heiglit  of 
the  complaint  varies,  according  to  Frerichs,  from  8.2  to  12.7, 
17.5  and  24.8  per  1000.  Christison  found  27  and  Heller  57  per 
1000.  The  quantity  lost  in  the  twenty-four  hours  varies  from 
80  to  about  400  grains  (Frerichs,  Gorup  v.  Besanez).  The 
natural  solid  constituents  of  the  urine  are  diminished  in  propor- 
tion to  the  obstruction  in  the  kidneys.  The  excretion  of  urea 
falls  to  100  or  200  grains  (from  400  to  500  grains  in  health)  and 
the  inorganic  salts  are  considerably  lessened.  Uric  acid  main- 
tains about  its  usual  quantity. 

The  blood  becomes  speedily  deteriorated  by  the  unnatural 
drain  through  the  kidneys.  It  becomes  more  watery  and  poorer 
in  albumen,  while  urea,  uric  acid,  and  the  extractives  are  unduly 
accumulated  in  it.  The  blood-corpuscles  diminish  in  number 
as  the  disease  proceeds,  and  a  generally  anemic  appearance  of 
the  body  is  produced.  Fibrine  is  usually  in  excess,  and  the 
blood  displays  a  buffy  coat.  The  fat  and  inorganic  salts  retain 
their  usual  proportion.  Frerichs  supplies  the  three  following 
analyses  of  the  blood  in  the  early  period  of  acute  Bright's  disease  : 

I.  ir.  III. 

Specific  gravity        .         .         .         .         .        1025  1022  1019 

1000  parts  of  serum  contained  : 

Water 908.10  915  88  938.9 

Solids     .         .         .         .         .         .       91.90  84.12  61.1 


Albumen 81.40  72.00  51.7 

Fat        .         .         .         .         .         .         1.42  1.58  \  q. 

Extractive  matters  and  salts.         .         9.09  10.59  j 

The  pulse  invariably  shows  high  tension  of  the  arterial  system 
when  examined  by  the  finger  or  by  the  sphygmograph.  In  rare 
cases  this  may  lead  to  a  recognizable  hypertrophy  of  the  heart, 
even  before  the  disease  has  passed  into  the  subacute  stage. 
Usually,  however,  cardiac  hypertrophy  is  absent  in  acute  Bright's 
disease.^ 

1  See  Wagner,  Ziems.  Cyclop.,  3d  ed.,  p.  131.  Also  Kiegel,  Berl.  klin.  Wochen.,' 
1882,  No.  28,  and  Zietsch*.  fiir  klin.  Med.,  1883,  p.  260. 


390  ACUTE  bright's  disease. 

After  the  disease  has  persisted  for  a  variable  period  of  a  few 
days. to  some  weeks,  it  proceeds  to  one  of  three  terminations, 
viz.,  recovery,  death,  or  lapse  into  the  chronic  state. 

When  the  case  is  about  to  terminate  favorably,  the  urine  in- 
creases in  quantity  to  three  or  four  pints  daily ;  its  density  falls 
below  the  natural  mean  (1012-1008);  and  the  blood,  renal  ele- 
ments, and  albumen  gradually  diminish  and  finally  disappear 
from  it.  At  the  same  time  the  skin  becomes  moist,  and  the 
serous  effusions  are  reabsorbed.  The  rate  of  progress  varies 
extremely.  If  albumen  has  totally  left  the  urine  in  six  weeks 
or  two  months,  the  recovery  may  be  considered  quick.  The 
shortest  period  that  I  have  known  to  elapse,  from  the  first 
symptoms  to  complete  reestablishment  of  the  normal  state,  has 
been  ten  days. 

Some  cases  reach  final  recovery  only  after  a  protracted  and 
interrupted  convalescence  of  many  months.  The  urine  during 
this  period  continues  abundant,  of  low  density,  occasionally  of 
pink  color  from  slight  admixture  of  blood.  The  anasarca  is 
also  apt  to  recur  and  disappear,  and  recur  again,  perhaps  several 
times,  accompanied  with  febrile  exacerbations  of  subacute  char- 
acter. In  one  such  case  observed  by  me  the  symptoms  finally 
subsided  in  five  months.  The  patient  was  seen  ten  months 
later,  and  the  urine  found  perfectly  free  from  albumen.  In  a 
second  case,  a  slight  admixture  of  blood  continued,  in  diminish- 
ing quantity,  for  more  than  twelve  months.  In  both  these 
instances,  and  in  a  third  similar  to  these,  the  characters  of  the 
urine  were  uniform;  it  was  copious  (three  or  four  pints  daily), 
of  low  density,  slightly  mixed  with  blood,  slightly  albuminous ; 
the  renal  derivatives  were  devoid  of  fat,  and,  throughout  the 
convalescence,  comparatively  scanty. 

Not  unfrequently,  in  the  ordinary  course  of  recovery  from 
acute  Bright's  disease,  the  renal  elements — both  casts  and  epi- 
thelium— show  slight  signs  of  fatty  changes.  This  circumstance 
is  apt  to  embarrass  the  diagnosis,  and  lead  to  the  suspicion  of 
the  existence  of  confirmed  and  chronic  Bright's  disease,  if  the 
case  first  come  under  observation  in  this  stage.  The  doubt  can 
only  be  solved  by  watching  the  progress  of  the  case  for  a  week 
or  two. 

But  matters  do  not  always  take  this  favorable  turn ;  and  two 
new  orders  of  symptoms  arise,  and  bring  life  into  imminent 
peril,  or  involve  it  in  destruction.  These  are  secondai\y  inflam- 
mations of  the  serous  membranes  and  the  lungs,  and  ursemic 
intoxication. 

Of  the  inflammatory  complications,  pericarditis  is  the  most 
surely  fatal,  but  it  is  rare.  Pneumonia  is  more  common;  it 
breaks  out  without  appreciable  exciting  cause,  and  usually  runs 
a  rapid  course  to  a  fatal  end.     Pleurisy  and  peritonitis  are  also 


DIAGNOSIS.  -391 

not  unfrequeiit,  but  greatly  Ighs  to  be  feared.  More  or  leHH 
bronchitis  exists  almost  invariably.  When  the  anasarca  rises 
to  an  extreme  degree,  the  integuments  of  the  legs  may  inflame, 
and  even  mortity.  These  secondary  inflammations  are  much 
more  common  in  the  later  stages  of  chronic  Bright's  disease 
than  in  the  acute  disorder. 

The  ursemic  phenomena  are  due  to  the  retention  in  the  blood 
of  the  excrementitious  matters  of  the  urine.  They  consist  in 
a  train  of  nervous  symptoms — headache,  vomiting,  diarrhoea, 
convulsions,  and  coma — which  are  frequent  incidents,  and  much 
to  be  feared  in  acute  Bright's  disease.  They  usually  follow  an 
excessive  diminution  or  suppression  of  the  urine  from  the  in- 
creasing obstruction  in  the  kidneys.  It  will  be  more  convenient 
to  postpone  their  consideration  to  a  future  section,  when 
urgemia,  in  connection  with  Bright's  disease  generally,  will  be 
discussed. 

Certain  deviations  from  the  usual  course  and  symptoms  are 
not  unfrequently  encountered.  Although  serous  effusion  gener- 
ally first  shows  itself  in  the  face,  under  the  eyes,  and  then 
invades  the  trunk  and  extremities,  it  may  begin  elsewhere — in 
the  feet,  hands,  or  scrotum ;  or  all  parts  of  the  body  may  swell 
up  simultaneously.  The  effusion,  too,  may  shift  its  place  from 
time  to  time,  or  it  may  be  poured  out  with  disproportionate 
copiousness  in  certain  localities  (lung,  pleura,  submucous  tissue 
of  the  glottis),  and  thereby  determine  sudden  accession  of 
alarming  or  fatal  symptoms. 

The  anasarca  commonly  disappears  some  days  or  weeks,  or 
€ven  many  months,  before  the  albumen  has  vanished  from  the 
urine;  but  sometimes  the  converse  is  the  case,  especially  in 
individuals  of  lax  frames  and  ansemic  tendency.  When  cases 
of  this  latter  class  come  under  observation  for  the  first  time 
after  the  urine  has  become  free  from  albumen,  they  are  very  apt 
to  mislead,  and  their  true  nature  can  only  be  recognized  by  a 
careful  sifting  of  the  patient's  previous  history. 

Diagnosis.— The  general  symptoms,  and  the  alterations  of  the 
urine,  are  so  significant  during  the  height  of  the  attack,  that  the 
disorder  can  scarcely  be  confounded  with  an}^  other.  But  when 
the  pyretic  stage  is  passed,  and  the  case  becomes  protracted, 
there  is  often  great  difficulty  in  determiningwhether  we  have  to 
deal  with  the  declining  periods  of  an  acute  and  curable  dis- 
order, or  w^itli  a  disease  which  has  already  lapsed  into  the 
chronic  and  irremediable  state,  or  with  a  disease  which  has  been 
chronic  from  the  first.  Chronic  Bright's  disease  is  subject  to 
occasional  febrile  recrudescences,  which  are  deceptively  like  an 
attack  of  the  acute  disorder.  The  signs  that  the  disease  is  acute 
and  recent  are:  free  presence  of  blood  and  renal  epithelium  in 
the  urine,  absence  of  fat  in  the  discharged  elements,  absence  of 


392  ACUTE  beight's  disease. 

long-standing  complications,  such  as  hypertrophy  of  the  left 
ventricle,  phthisis,  caries,  necrosis,  and  joint  disease.  A  careful 
consideration  of  the  previous  history  and  of  the  ostensible  cause 
of  the  disorder  is,  also,  of  diagnostic  importance.  The  less 
clearly  a  case  can  be  traced  to  a  definite  exposure  to  cold,  a  bout 
of  drinking,  or  to  scarlet  fever,  or  some  other  zymotic  disease,  the 
more  reason  is  there,  pro  tanto,  to  fear  that  confirmed  Bright's 
disease  is  established. 

Prognosis. — Precise  data  concerning  the  fatality  of  acute 
Bright's  disease  are  wanting.  A  large  majority  of  the  cases 
undoubtedly  recover.  Frerichs  reckons  the  recoveries  as  two- 
thirds  of  the  individuals  attacked.  Probably  this  proportion  is 
below  the  truth  if  the  scarlatinal  cases  be  included. 

The  signs  of  approaching  resolution  are:  increased  discharge 
of  urine,  diminished  impregnation  of  it  with  blood  and  albu- 
men, subsidence  of  the  febrile  phenomena,  of  the  anasarca  and 
serous  effusions,  and  restoration  of  the  cutaneous  transpiration. 
At  the  same  time,  the  countenance  loses  its  stupid  expression 
and  its  anaemic  hue,  and  resumes  its  ordinary  healthy  aspect. 
The  coexistence  of  all  these  signs  leaves  no  doubt  of  advance 
toward  a  favorable  issue:  but  the  occurrence  of  some  of  them 
without  the  others  must  not  lead  to  too  sanguine  expectations. 
The  anasarca  may  disappear  totally,  and  blood  cease  to  tinge 
the  urine ;  the  quantity  of  the  secretion  may  increase  consider- 
ably, the  pyrexia  pass  away,  and  the  general  well-being  of  the 
patient  improve  greatly;  but  if  the  urine  continue  to  contain  a 
considerable  amount  of  albumen,  there  is  strong  reason  to  ap- 
prehend that  the  disease  is  lapsing  into  a  chronic  state,  or  that 
the  amendment  is  but  a  temporary  lull  in  the  symptoms,  to  be 
followed  at  no  distant  period  by  an  exacerbation,  which  shall 
prove  more  disastrous  than  the  original  attack.  Recovery  can- 
not in  any  case  be  considered  complete,  until  the  urine  has  be- 
come perfectly  free  from  every  trace  of  albumen. 

If  the  urine  become  progressively  scantier,  of  higher  density, 
and  more  abundantly  charged  with  albumen,  tube-casts,  and 
renal  epithelium,  the  worst  consequences  are  to  be  feared.  The 
advent  of  inflammatory  complications,  of  oedema  of  the  lungs 
or  glottis,  and,  above  all,  of  decided  signs  of  uremic  poisoning, 
are  of  equally  evil  augury,  and  leave  but  slender  hopes  of  the 
final  preservation  of  life. 

The  prognosis  is  decidedly  more  favorable  in  the  aged  than  in 
the  young.  I  have  several  times  seen  the  disease  in  persons 
over  sixty,  and  once  in  a  man  on  the  verge  of  eighty ;  but  in 
most  of  them  the  disease  proved  mild,  and  in  all  of  them  it 
issued  in  recovery. 

Etiology. — Acute  Bright's  disease,  though  not  absolutely  con- 
fined to  any  age,  occurs,  in  the  immense  majority  of  cases,  in 


TREATMENT.  3I»3 

childhood  and  youth.  The  individuals  attacked  are  commonly 
of  good  previous  health  ;  in  two  instances,  how^ever,  I  have  seen 
the  disease  complicated  with  acute  pulmonary  tuberculosis. 

The  exciting  cause  is  usually  some  delinite  exposure  to  cold 
(a  damp  bed,  wet  clothes,  lying  or  sleeping  on  the  damp  ground, 
sitting  in  a  current  of  cold  air,  drinking  cold  water  when  in  a 
state  of  perspiration),  or  a  bout  of  drinking.  A  large  propor- 
tion of  the  cases  are  sequelae  of  scarlet  fever,  or  (much  more 
rarely)  of  some  other  zymotic  disease.  Albuminuria,  and  some- 
times all  the  other  phenomena  of  acute  Bright's  disease,  have 
been  described  in  cases  of  acute  intestinal  catarrh.  Some  cases 
are  due  to  pregnancy. 

Treatment. — If  the  case  is  seen  at  the  time  of  invasion,  the 
patient  should  be  at  once  confined  to  bed,  swathed  in  flannels, 
and  made  to  lie  between  the  blankets.  The  loins  should  be 
immediately  cupped  to  eight  or  twelve  ounces  (in  children  to 
two  or  three  ounces).  After  the  abstraction  of  blood,  a  large 
linseed-meal  poultice  should  be  applied,  hot,  to  the  loins,  and 
changed  every  three  hours.  A  hot-water  bath  or  a  hot-air  bath 
should  be  administered  every  evening,  or  every  second  evening. 
When  no  conveniences  for  a  hot-water  bath  exist,  an  excellent 
substitute  is  found  in  the  "  blanket-bath."  A  large  thick  blanket 
is  wrung  as  dry  as  possible  out  of  boiling  water,  and  wrapped 
round  the  body  of  the  patient;  the  bedclothes  are  then  heaped 
on.  In  twenty  minutes  or  half  an  hour,  the  hot  blanket  is 
removed,  and  the  surface  quickly  dried  with  a  warm  soft  towel. 

The  bowels  should  be  freely  acted  on  every  other  morning 
by  an  active  purge,  such  as  the  compound  jalap  powder.  An 
endeavor  should  also  be  made  to  allay  the  fever  and  restore  the 
action  of  the  skin,  by  citrate  of  potash  draughts,  given  every 
two  hours,  in  effervescence,  or  a  mixture  of  the  liq,  amnion, 
acet,  in  two  or  three  drachm  doses,  with  fifteen  drops  of  tinc- 
ture of  henbane  in  an  ounce  of  inf  lini.  Dr.  Barlow  recom- 
mends tartar  emetic  in  doses  from  J  to  |  of  a  grain.  I  have 
myself  employed  the  same  remedy  with  the  best  effects,  every 
four  hours.  Dr.  Johnson  also  speaks  highly  of  antimonial  wine, 
sometimes  combined  with  Dover's  powder. 

The  diet  should  be  composed  of  light  farinaceous  substances, 
with  milk,  beef-tea,  and  broths.  Flesh  meat  in  any  form  is 
objectionable  in  the  early  stage. 

The  abstraction  of  blood  must  be  cautiously  practised,  on 
account  of  the  tendency  to  aiiEemia  in  the  later  periods  of  the 
attack;  and  if  the  patient's  health  is  broken  by  previous  dis- 
ease, or  is  constitutionally  weak,  even  local  depletion  is  better 
omitted.  If  severe  headache,  coma,  or  convulsions  occur,  the 
cupping  may  be  repeated.  In  very  threatening,  sthenic  cases, 
where  the  fever  runs  high,  venesection  may  be  practised. 

"When  the  fever  has  abated,  and  the  anasarca  is  yielding,  the 


894  ACUTE  bright's  disease. 

more  active  measures  should  be  discontinued,  or  pursued  in  a 
less  active  manner;  but  the  eiibrts  to  restore  and  maintain  the 
action  of  the  skin  should  be  persevered  in.  In  the  later  periods, 
when  convalescence  has  been  fairly  established,  preparations  of 
iron  should  be  substituted  for  the  alkaline  and  diaphoretic  reme- 
dies. It  is  always  well  to  begin  with  small  doses,  and  to  feel 
one's  way.  A  too  early  resort  to  ferruginous  preparations  may 
be  followed  by  a  return  of  the  acute  symptoms.  When  iron  is 
tolerated,  it  acts  with  great  benefit,  and  hastens  in  a  marked 
manner  the  disappearance  of  blood  and  albumen  from  the  urine. 
My  experience  agrees  with  that  of  Dr.  Parkes,  that  gallic  acid 
exercises  no  beneficial  influence  in  the  acute  disorder. 

The  use  of  mercury  is  objectionable,  on  account  of  the  extreme 
susceptibility  of  patients  suffering  from  Bright's  disease  to  the 
physiological  effects  of  the  drug.  Severe  salivation  has  been 
known  to  follow  very  small  doses.  In  one  of  my  patients  two 
grains  of  blue  pill,  administered  with  extract  of  colocynth  on 
two  alternate  mornings,  produced  profuse  ptyalism. 

The  obstinate  vomiting  which  occasionally  prevails,  may  be 
combated  with  creasote,  or  small  doses  of  chloroform,  given  in 
iced  solutions.  A  careful  revision  of  the  diet  should  also  be 
made.  The  gastric  symptoms  are  sometimes  due  to  direct 
sympathy  with  the  renal  irritation,  and  sometimes  to  genuine 
ursemic  poisoning.  The  treatment  of  uraemia  will  be  considered 
in  a  separate  section. 

The  secondary  thoracic  inflammations  present  great  difficulty 
in  their  management ;  they  commonly  set  in  when  the  patient 
is  no  longer  in  a  fit  state  to  bear  the  ordinary  antiphlogistic 
means;  and  they  run  their  course  with  unusual  severity  and 
rapidity.  Counter-irritants  and  revulsives  may,  however,  be 
energetically  employed.  Cantharides  and  turpentine  should  be 
avoided,  from  their  special  irritating  effect  on  the  kidneys;  but 
hot-water  applications,  mustard  poultices,  and  chloroform  epi- 
thems  may  be  applied  locally  over  the  chest,  and  to  more  distant 
parts — the  calves  of  the  legs,  the  feet,  etc.  Dry  cupping  over 
the  chest  is  also  a  safe  and  sometimes  valuable  remedy. 

When  a  favorable  issue  has  been  obtained,  unusual  care  is 
required  to  guard  against  relapses,  to  which  the  patients  con- 
tinue liable  for  a  considerable  period.  The  slightest  exposure 
is  sometimes  sufficient  to  reawaken  the  pyrexia,  and  to  cause 
the  reappearance  of  albumen  and  blood  in  the  urine.  A  com- 
plete suit  of  flannels  is  essential ;  and,  as  a  rule,  the  conva- 
lescent should  not  be  permitted  to  leave  his  room  until  the 
albumen  has  disappeared  from  the  urine.  When  that  comes  to 
pass  (or  before,  if  the  case  prove  very  lingering),  change  of  air 
to  a  warm  sheltered  locality  is  likely  to  be  highly  beneficial,  and 
to  hasten  the  restoration  of  the  impoverished  blood. 


TREATMENT.  395 

Objections  have  been  made,  on  theoretical  grounds,  to  the  use 
of  the  saline  diuretics  (acetate  and  citrate  of  potash)  in  acute 
Bright's  disease.  Experience  has  proved,  however,  that  they 
may  be  employed  with  great  advantage.  They  l>ecome  changed 
in  the  primce  vice  into  alkaline  carbonates,  and  these  diminish 
the  acidity  of  the  urine,  and  render  it  more  bland  as  it  jjerco- 
lates  the  renal  substance.  In  a  disease  which  tends  to  spon- 
taneous recovery  under  simple  hygienic  and  prophylactic  treat- 
ment, it  is  necessarily  a  matter  of  extreme  difficulty  to  l;ring 
home  the  evidence  of  the  curative  power  of  drugs;  but  in  a 
considerable  number  of  cases  of  acute  Bright's  disease,  coming 
under  treatment  early,  I  have  obtained  almost  invariably  the 
best  results  by  the  free  administration  of  citrate  of  potash.  And 
in  no  instance  where  the  urine  has  been  rendered  alkaline  in 
the  first  week  of  the  complaint,  have  I  observed  the  more  severe 
ursemic  symptoms,  or  secondary  inflammations.  In  the  later 
periods,  when  the  fever  has  altogether  subdivided,  while  the  urine 
still  continues  bloody  and  albuminous,  the  same  medicament 
has  not  proved  of  any  service  in  my  hands. 

Digitalis  and  broom-tops  may  be  used  freely  in  any  stage  to 
combat  the  dropsy.  Dr.  Cbristison  recommends  a  combination 
of  digitalis  and  bitartrate  of  potash  as  superior  to  either  remedy 
given  singly.  "  The  former  was  usually  given  in  the  dose  of 
one  or  two  grains  of  the  powder,  in  the  form  of  a  pill,  three 
times  a  day,  or  in  the  dose  of  ten,  fifteen,  or  twenty  minims  of 
the  tincture,  three  times  daily  in  a  little  distilled  water  of  cinna- 
mon or  cassia.  The  cream  of  tartar  was  administered  thrice  a 
day  in  the  quantity  of  a  drachm  and  a  half,  or  two  drachms, 
with  about  five  ounces  of  water.  Diuresis  may  generally  be 
induced  by  such  means  in  the  course  of  three  or  four  days, 
sometimes  sooner  —  seldom,  however,  if  delayed  beyond  the 
seventh  day." 

Dickinson  lays  considerable  stress  on  the  desirability  of 
encouraging  the  patient  to  drink  freely  of  water,  with  a  view 
of  facilitating  the  elimination  of  the  urinary  solids  by  the  kid- 
neys, and  thus  diminishing  the  risk  of  ursemic  intoxication. 

Hamburger  speaks  strongly  in  favor  of  quinine  in  scarlatinal 
dropsy,  after  the  pyrexia  has  abated.  He  gives  to  children  li 
or  2  grains,  and  to  adults  3  to  4  grains,  twice  a  day.  Of  47 
severe  cases  thus  treated  he  obtained  amendment  in  44,  either 
immediately  or  in  a  few  days.     ("Prag.  Yierteljahrsch,"  1861.) 


CHAPTER    lY. 

CHRONIC  BRIGHT' S  DISEASE. 
ANATOMICAL  CHANGES  IN  THE  KIDNEYS. 

The  kidneys  of  persons  dying  of  chronic  Bright's  disease 
present  three  chief  types  of  alteration,  viz.  : 

Type  I. — Kidney  smooth,  tvhite,  and  enlarged;  in  extreme  cases, 
rarely  met  with,  kidney  atrophic  (chronic  nephritis). 

Type  II. — Kidney  granular,  broionish,  or  red,  and  contracted 
(cirrhotic  kidney). 

Type  III. — Kidney  lardaceous  or  waxy  (so-called  amyloid  degen- 
eration). 

The  special  clinical  history  pertaining  to  each  of  these  ana- 
tomical types  has  not  been  made  out  with  sufficient  precision  to 
enable  them  to  be  invariably  recognized  during  life;  but  much 
light  has,  in  recent  years,  been  thrown  on  the  subject,  enough  to 
permit  a  sjaiopsis  of  the  symptoms,  and  conditions  of  origin,  of 
the  three  types  to  be  presented. 

These  types  are  not  always  found  simple  and  unmixed.  On 
the  contrary,  the  main  type  of  alteration  present  in  any  case  is 
often  complicated  by  superadded  changes  belonging  to  another 
type.  Thus  the  smooth  white  kidney  becomes  not  unfrequently 
affected  with  waxy  degeneration  or  with  interstitial  growth ; 
and  the  granular  and  the  waxy  kidney  are  each  liable  to  inflam- 
matory attacks,  which  bring  about  changes  belonging  to  the 
first  type.  In  this  way  a  complex  anatomical  state  is  produced 
which  is  associated  with  a  complex  clinical  history. 

1.  Smooth  White  Kidney. 
( Chronic  Nephritis. ) 

The  structural  changes  in  the  smooth  white  kidney  are  simi- 
lar in  kind  to  those  already  described  as  pertaining  to  acute 
Bright's  disease,  but  advanced  to  a  further  stage;  the  surface 
continues  perfectly  smooth;  the  organ  is  considerably  enlarged  ; 
the  capsule  is  thin  and  easily  stripped  ofiT.  Conspicuous  stellate 
patches  of  bloodvessels  are  seen  on  the  white  or  mottled  surface. 
On  section  the  cortical  substance  is  seen  to  be  greatly  increased ; 
its  color  is  ivory-white,  or  (in   cases  of  fatty  transformation) 


ANATOMICAL    TYPES  —  SMOOTH     KIDNEY.  397 

yellowish.  The  cones  retain  their  usual  color,  Imt  tliey  appear 
conspicuously  red  from  contrast  with  the  abnormal  wliiteness  of 
the  cortex. 

The  microscopic  changes,  as  (lescri})e(l  by  Dickinson  and 
Grainger  Stewart,  are  essentially  confined  to  the  uriniferous 
tubes.  The  epithelial  lining  of  the  tube  is  enormously  in- 
creased in  quantity,  and  the  tubes  are  thereby  distended  and 
enlarged.  The  cells  are  swollen,  generally  o[)aque  and  granular, 
and  often  largely  charged  with  oily  particles.  In  the  pure  form 
the  intertubular  tissue  is  not  altered,  but  commonly  it  shows  a 
little  increase.  In  the  progress  of  the  disease  a  number  of  the 
distended  tubes  and  their  contents  are  broken  up  into  a  granu- 
lar debris,  and  afterwards  absorbed.  Transparent  fibrinous 
effusion  and  blood  are  sometimes  seen  within  the  tubules.  The 
Malpighian  corpuscles  are  either  of  their  natural  size  or  only 
slightly  enlarged,  and  their  capsules  are  thin,  as  in  the  natural 
kidney.  The  cones  undergo  changes  of  a  corresponding  char- 
acter with  those  of  the  cortex,  but  less  developed  ;  and  fibrinous 
casts  are  found  occupying  the  interior  of  the  straight  tubes. 

The  large  smooth  kidney  generally  remains  large  and  smooth 
to  the  last;  but,  sometimes,  if  the  patient  survive  sufficiently 
long,  the  enlargement  gives  place  to  a  progressive  dwindling  ; 
and  in  very  extreme  cases,  the  kidney  may  be  reduced  to  a 
weight  of  only  an  ounce,  or  even  less.  This  dwindling  is, 
however,  not  an  invariable  event,  even  when  the  patient  sur- 
vives for  some  years.  Dr.  Wilks  relates  the  following  case  in 
point : 

"A  young  woman,  set.  23,  had  scarlatina  three  years  before  death. 
There  was  very  slight  eruption  ;  dropsy  soon  followed,  which  lasted  a 
year.  Then  the  patient  was  slightly  better,  but  remained  an  invalid, 
with  oedema  of  the  legs,  until  the  last  five  months,  when  very  extensive 
and  general  dropsy  came  on  and  persisted.  The  urine  was  then  scanty, 
dark,  and  contained  exudative  deposit.  She  had  three  epileptiform  fits, 
and  death  subsequently  ensued  from  pleuritis  and  pericarditis.  Lungs 
were  found  very  oedematous.  The  aorta  and  arteries  were  covered  with 
an  atheromatous  deposit;  and  the  kidneys  were  large  and  white,  with  an 
abundance  of  deposit,  much  of  which  had  undergone  a  fatty  change." 
("  Guy's  Hosp.  Rep.,"  2d  series,  vol.  viii.  p.  243.) 

When  the  smooth  kidney  becomes  atrophied,  the  capsule  is 
somewhat  thickened,  and  disposed  to  adhere  to  the  renal  sur- 
face, and  slight  superficial  depressions  make  their  appearance, 
giving  the  organ  a  slightly  granular  character. 

This  atrophic  condition  seems  to  he  brought  about  by  a 
destruction  and  gradual  absorption  of  the  distended  tubules 
and  their  epithelial  contents.  The  cortical  substance  is  thus 
progressively  consumed  while   the   pj'-ramidal  portions   retain 


398  CHRONIC  bright's  disease. 

their  natural  dimensions.  The  bloodvessels  are  found  much 
thickened,  and,  according  to  Grainger  Stewart,  there  is  a  rela- 
tive increase  of  the  fibrous  stroma,  but  by  no  means  to  so  great 
an  extent  as  in  the  cirrhotic  kidney. 

The  large  white  kidney  is  not  unfrequently  greatly  infiltrated 
with  fat.  Oily  particles  are  found  in  great  numbers  in  the  sub- 
stance of  the  epithelium  and  lying  free  in  the  tubules.  It  con- 
stitutes one  form  of  the  "  fatty  kidney."  This  change  some- 
times begins  at  an  early  stage  of  the  disease,  but  it  only  reaches 
an  extreme  degree  in  long-standing  cases.  Fatty  transformation 
is  much  more  frequent  when  the  disease  has  arisen  from  cold 
than  when  it  has  followed  scarlatina. 

Synopsis  of  Symptoms  and  Conditions  of  Origin. — The 
smooth  kidne}^  is  found  in  those  cases  in  which  chronic  Bright's 
disease  has  followed  on  the  acute  disorder.  The  invasion  of  the 
disease  has  been  sudden,  and  it  can  usually  be  traced  to  some 
definite  exciting  cause,  either  cold  or  scarlatina.  I  have  also 
seen  the  large  white  kidney  in  chronic  Bright's  disease  follow- 
ing repeated  pregnancies,  and  in  a  case  arising  in  the  course  of 
phthisis. 

The  average  age  of  106  cases  of  smooth  large  kidney,  ex- 
amined by  Dickinson,  was  28.2  years;  in  11  cases  of  smooth 
dwindled  kidney  the  average  age  was  43.6  years;  whereas  in 
250  cases  of  granular  kidney  the  average  age  was  50.2  years. 

Serous  efl^usion  is  an  almost  invariable  coincidence;  the  body 
is  commonly  bloated  with  dropsy;  the  face  pale  and  puffy,  and 
the  cutaneous  surface  conspicuously  white,  smooth  and  glossy. 
There  is  also  a  markedly  greater  tendency  to  secondary  inflam- 
mations, and  to  ureemic  accidents,  than  in  granular  kidney,  but 
less  to  valvular  heart  disease  and  hypertrophy  of  the  left 
ventricle. 

The  urine  is  generally  scanty.  Its  specific  gravity  is  either 
normal,  or  somewhat  raised  above  the  usual  average.  It  is  pale 
and  cloudy,  but  sometimes  smoky  and  tinged  with  blood.  On 
standing,  it  deposits  a  quantity  of  amorphous  renal  debris  and 
casts  of  tubes.  The  casts  are  of  various  character,  "  epithelial," 
"  granular,"  "  fatty,"  and  "  hyaline."  Cells  having  the  appear- 
ance of  pus-corpuscles  are  common  towards  the  later  periods. 

The  disease  is  of  shorter  duration  than  the  granular  kidney. 
In  fatal  cases  the  ordinary  duration  of  the  disease  is  under  six 
months.  Temporary  recoveries  and  relapses  are  frequent. 
Permanent  recovery  may  be  hoped  for  even  after  the  lapse  of 
a  year  or  more.  In  these  protracted  cases  the  albuminuria 
continues  long  after  the  dropsical  symptoms  have  passed  away. 
I  have  known  cases  in  which  abundant  albuminuria  has  per- 
sisted for  more  than  a  year  after  all  other  symptoms  of  disease 
had  ceased.     At  length  the  albuminuria  has  gradually  disap- 


ANATOMICAL    TYPES  —  GRAN  ULAK    KIDNEY.  399 

pearcd,  and  the  reality  iXH  well  an  the  appearance  of  health  lias 
been  established. 

Quite  exceptionally  the  disease  may  be  protracted  for  several 
years.  Dr.  Johnson  records  an  instance  which  endured  for  ten 
years,  with  good  preservation  of  health  for  a  portion  of  that 
period.  Nine  years  before  death,  the  urinary  deposit  clearly 
indicated  fatty  degeneration  of  the  kidneys.  After  death,  the 
kidneys  were  found  dwindled  to  an  ounce  and  three-quarters  for 
the  pair.^ 

2.  Granular  Contracting  Kidnky. 

[Cirrhotic  Kidney.) 

The  gland  is  diminished  in  size  and  reduced  in  weight.  In 
extreme  cases  the  weight  of  the  kidney  is  reduced  to  two  or 
three  ounces,  or  less.  Its  surface  is  rough,  and  beset  with 
numerous  rounded  elevations,  varying  from  the  size  of  a  pin's 
head  to  a  hemp-seed,  or  even  a  small  pea.  The  capsule  is 
opaque,  thickened,  and  adherent  to  the  subjacent  surface,  so  that 
it  cannot  be  peeled  ofi'  without  tearing  the  glandular  structure. 
In  certain  spots  the  capsule  sinks  into  the  substance  of  the 
cortex,  and  divides  the  kidney  irregularly — giving  it  a  lobular 
appearance.  On  section,  the  cortex  is  manifestly  atrophied,  as 
compared  with  the  cones,  and  forms  a  thin  rim  of  only  a  line, 
or  less,  in  thickness  around  the  bases  of  the  pyramids.  It  has 
a  red,  or  brownish-red  color,  and  a  coarse  granular  texture. 
The  entire  organ  is  tough  and  resistant.  In  the  granular  kidney 
produced  by  gout  there  may  be  seen  in  the  pyramidal  portion 
longitudinal  white  or  yellowish  streaks,  caused  by  a  deposit  of 
urate  of  soda. 

When  a  thin  section  of  a  granular  kidney  is  placed  under  the 
microscope,  the  secreting  tissue  is  found  to  have  undergone  ex- 
tensive destruction.  The  Malpighian  bodies  are  shrunk  to  half 
their  size,  and  unnaturally  crowded  together.  Their  vascular 
tufts  are  embraced  in  a  fibrous  and  granular  investment,  and,  in 
extreme  instances,  compressed  into  an  impermeable  knot  at  the 
bottom  of  their  capsules. 

The  investment  is  formed  by  an  increase  of  the  fibrous  tissue 
surrounding  the  glomerulus,  or  by  a  swelling  and  fibrous  thick- 
ening of  Bowman's  capsule  and  its  lining  epithelium.  The 
vascular  tuft  itself  is  not  unfrequently  transformed  into  a  fibrous 
mass,  and  it  may  also  undergo  a  colloid  change. 

The  uriniferous  tubes  are  altered  in  various  ways,  and  to 
various  degrees.  Some  are.  denuded  of  epithelium  and  reduced 
to  mere  tubular  threads;  others,  equally  denuded,  contain  glassy 

1  Med.-Chir.  Trans.,  vol.  xlii   p    160 


400  CHRONIC  bright's  disease. 

fibrinous  cylinders;  while  others  are  crammed  with  broken-up 
epithelium.  Many  of  the  convoluted  tubes  are  seen  to  be  much 
diminished  in  size  and  lined  by  a  layer  of  cubical  epithelium 
instead  of  the  large  granular  cells  commonly  found  there. 

Oil  is  found  not  unfrequently  both  in  the  fibrinous  exudation 
and  in  the  disintegrated  epithelium,  but  not  so  commonly  nor 
so  abundantly  as  in  the  smooth  kidney.  Amid  tubes  changed 
to  this  degree,  are  found  others  not  much  altered,  and  lined  with 
their  proper  and  healthy  epithelial  investment.  The  basement 
membrane  of  the  tubes  is  thickened.  Between  the  wasted 
structures  lies  a  large  quantity  of  adventitious  connective  tissue, 
which  gives  the  organ  its  peculiar  toughness. 

The  arteries  of  the  kidney  show  considerable  changes.  They 
may  show  thickening  of  all  their  coats.  Dr.  George  Johnson 
first  pointed  out  the  great  increase  in  the  muscular  coat,  and 
although  his  position  has  been  attacked  by  some,  it  has  been 
abundantly  confirmed  by  other  observers.  Dr.  Klein  has  ob- 
served what  is  probably  the  early  stage  of  this  change  in  the 
scarlatinal  kidney,  where  he  found  proliferation  of  the  muscle 
nuclei  in  the  walls  of  the  arterioles.  The  adventitia  frequently 
shows  fibrous  thickening,  which  merges  into  the  general  connec- 
tive tissue  of  the  kidney,  while  the  intima  very  often  is  the  seat  of 
chronic  endarteritis,  which  may  considerably  diminish  the 
lumen  of  the  vessel. 

It  is  only  rarely  that  the  granular  kidney  is  encountered  in 
the  early  stage  of  its  development.  When  such  is  the  case, 
thickening  of  the  capsule  and  slight  granulation  of  the  surface 
are  found  to  precede  contraction,  so  that  the  organ  at  this  period 
preserves  its  normal  volume.  The  granular  kidney,  in  the  con- 
tracted state,  allows  injections  to  penetrate  imperfectly.  Dick- 
inson found  that  when  a  stream  of  warm  water  was  propelled 
through  the  bloodvessels,  a  very  considerably  less  quantity 
passed  in  a  given  time  than  through  a  healthy  kidney — less  also 
than  through  the  large  smooth  kidney — showing  that  the  permea- 
bility of  the  gland  to  the  blood-stream  was  greatly  lessened. 
In  the  healthy  kidney,  the  mean  discharge  through  the  renal 
veins  in  ten  minutes  was  119  ounces ;  in  the  large  smooth  kid- 
ney, 90  ounces;  and  in  the  granular  contracted  kidney,  25 
ounces.  This  diminished  permeability  is  not  wholly  due  to  the 
cirrhotic  state  of  the  intertubular  matrix,  but  partly  to  thicken- 
ing of  the  walls  of  the  minute  arteries  of  the  kidney,  as  has 
been  pointed  out  by  Dr.  G.Johnson.  ("Brit.  Med.  Journ.," 
April,  1870.) 

Thoma  has  obtained  results  similar  to  those  of  Dr.  Dickin- 
'son,  using  as  the  injecting  fluid  either  defibrinated  ox-blood  or 
gelatine  solutions.  He  lays  stress  on  the  endarteritis  as  a  cause 
of  obstruction  to  the  blood  flow,  but  also  shows  that  the  oblitera- 


ANATOMICAL    'J'YPES — GKANULAR     KIDNEY.  401 

tioii  of  the  glomeruli  may  take  part  in  this,  and  that  the  arteries 
of  the  kidney  allow  of  more  easy  transudation  through  their 
walls.  The  influence  of  the  destruction  of  small  vessels  is  to 
some  extent  counteracted  by  anastomoses  wliich  are  set  up. 
Thus,  when  the  vascular  tuft  of  the  gh)meruhis  is  destroyed, 
a  direct  communication  is  established  between  the  aflerent 
and  efferent  vessels;  when  the  glomerulus  becomes  cystic,  a 
system  of  capillaries  running  around  the  cyst-wall  again  estab- 
lishes communication  between  the  afferent  and  efferent  vessels; 
in  addition,  the  normal  anastomoses  between  the  branches  of  the 
renal  and  neighboring  arteries  become  dilated,  and  carry  off  a 
larger  amount  of  blood  than  usual. 

Of  the  intimate  nature  of  the  process  which  finally  brings 
about  this  state  of  the  kidney,  there  are  conflicting  opinions. 
Dr.  Johnson  believes  that  the  mischief  begins  in  the  epithelial 
cells,  and  that  the  tibrous  tissue  is  the  remnant  of  atrophied 
tubes.  Dickinson  and  Grainger  Stewart  describe  the  process  as 
originating  in  the  intertubular  matrix,  and  as  consisting  essen- 
tially in  an  enormous  hypertrophy  of  the  tibrous  stroma  of  the 
organ.  By  the  pressure  and  contraction  of  this  tibrous  material 
the  uriniferous  tubes  and  Malpighian  corpuscles  are  extensively 
destroyed,  and  the  size  of  the  kidney  is  progressively  reduced. 
According  to  Dickinson,  the  tibrous  growth  begins  beneath  the 
capsule,  and  then  penetrates  into  the  interior  of  the  cortex.  The 
points  where  the  tibrous  processes  penetrate  are  depressed,  and 
when  these  are  numerous  and  distributed  with  tolerable  regu- 
larity, the  appearance  of  superticial  granulation  is  produced. 
The  disease  thus  travels  from  the  surface  towards  the  central 
parts,  and  eventually  involves  the  pyramids.  It  must  be  admitted, 
however,  that  in  many  specimens  the  fibrous  tissue  can  be  seen 
grouped  round  the  glomeruli  and  the  arteries,  and  not  proceed- 
ing from  the  capsule. 

Sir  William  Grull  and  Dr.  Sutton  propound  a  difierent  view 
of  the  pathology  of  granular  kidney.  They  assert  that  the 
morbid  process  consists  in  the  deposit  of  a  "  hyalin-tibroid  " 
material  in  the  tibrous  coats  of  the  small  arteries  and  capillaries. 
This  morbid  change  is  attended  with  atrophj'  of  the  subjacent 
tissues :  it  is  not  contined  to  the  kidnej's,  but  may  prevail  ex- 
tensively throughout  the  area  vasculosa.  Although  it  gener- 
ally begins  in  the  kidneys,  there  is  evidence  of  its  beginning 
primarily  in  other  organs.  A  brief  account  of  these  views  is 
given  further  on  in  treating  of  the  connection  of  Bright's  dis- 
ease with  diseases  of  the  heart  and  vascular  system. 

The  development  of  cysts  is  very  common  in  the  granular 
kidney.  They  vary  in  size  from  a  pin's  head  to  a  pea  or  a 
hazel-nut ;  but  many  are  so  minute  that  they  can  only  be  de- 
tected by  the  microscope,  not  being  larger  than  the  width  of  the 

26 


402  CHRONIC   bright's  disease. 

uriniferous  tubes.  Mr.  Simon  believes  that  they  are  formed  by 
an  immense  dihitation  of  epithelial  cells — a  development  that 
seems  incredible,  considering  the  fragility  of  the  outer  portions 
of  these  cells;  and  one  that  would  be,  so  far  as  I  know,  without 
parallel  in  histogenesis.  A  better  sustained,  and  more  com- 
monly accepted,  view  is,  that  they  are  produced  by  obstruction 
of  the  uriniferous  tubes  with  exudation,  at  intervals,  or  by  com- 
pression of  their  walls  at  interrupted  spots  by  the  contracting 
adventitious  tissue.  The  spaces  thus  enclosed  become  distended 
with  a  serous  fluid,  and  are  sometimes  found  lined  with  an 
epithelial  layer.  Their  contents  are  not  urinous,  but  consist  of 
an  albuminous  saline  solution  or  of  a  colloid  mass.  In  the  cones 
they  are  sometimes  elongated  and  placed  end  to  end  like  a  string 
of  sausages  (Dickinson).  {See  Cysts  arid  Cystic  Degeneration  in 
the  Kidneys.) 

Synopsis  of  Symptoms  and  Conditions  of  Origin. — The  granu- 
lar kidney  is  found  in  the  vast  majority  of  those  cases  of  Bright's 
disease  which  are  chronic  from  the  beginning — those  which 
commence  insidiously,  without  definite  exciting  cause.  Dropsy 
is  altogether  absent  in  a  considerable  proportion  (perhaps  in 
a  quarter — according  to  some,  in  one-half)  of  the  cases,  and 
when  present,  it  is  commonly  slight  and  limited  to  oedema  of 
the  ankles  and  legs,  or  a  puffiness  under  the  eyes.  It  often  dis- 
appears for  a  while,  and  returns  again. 

The  disease  may  run  a  latent  course  for  months  and  years. 
A  deep  constitutional  cachexy  is  associated  with  it  in  a  large 
proportion  of  cases.  The  subjects  of  it  are  more  advanced  in 
years  than  those  of  the  smooth  large  kidney  (see  p.  398).^  The 
cutaneous  surface,  though  pale  and  anaemic,  has  not  the  con- 
spicuous whiteness  of  the  preceding  type,  and  the  features  are 
often  pinched  and  sallow.  With  this  type  of  Bright's  disease 
are  especially  associated  hypertrophy  of  the  left  ventricle  and 
certain  changes  in  the  small  arteries  and  in  the  retina,  which 
will  be  more  full}^  noticed  in  a  future  page.     {See  Complications.) 

The  urine  is  copious — three  or  four  pints  a  day — and  of  low 
specific  gravity ;  the  quantity  of  alibumen  is  comparatively 
small;  in  rare  cases  it  may  even  be  temporarily  absent  from  the 
urine.  Toward  the  termination  of  the  disease,  however,  the 
urine  becomes  scanty,  or  even  suppressed.  The  deposit  is 
slight,  composed  of  hyaline  and  granular  casts,  with  very  slight 
admixture  of  epithelium,  not  often  fatty:  the  deposit  is  often 
so  scanty  that  it  may  escape  detection,  or  there  may  really  be 
none.     As  a  rule,  blood  is  absent. 

1  Young  persons  and  e\en  children  are,  however,  sometimes  the  victims  of  this 
type  of  Bright's  disease.  I  saw  a  remarkable  example  with  Dr.  Barlow,  in  a  child 
of  5  years,  of  which  Dr.  Barlow  has  given  an  elaborate  account  in  the  Lancet 
for  Aug.  1,  1874. 


ANATOMICAL    TYPES.  403 

The  common  predisposing  causes  are  habitual  intemperance, 
gout,  lead  poisoning,  repeated  exposure  to  cold,  and  extensively 
distributed  fatty  degeneration  of  the  tissues. 


As  these  two  types — the  smooth  large  white  kidney,  and  the 
granular  red  contracting  kidney — constitute  the  vast  majority 
of  cases  -of  Bright's  disease,  the  question  of  the  oneness  or 
multiformity  of  JBright's  disease  has  mostly  been  limited  to  the 
inquiry — whether  the  latter  is  the  ultimate  stage  ot  the  former, 
or  whether  the  two  are  distinct  from  first  to  last. 

Reinhardt  and  Frerichs  believe  that  the  large  white  kidney 
will,  if  the  patient  survive,  eventually  become  granular,  red,  and 
contracted.  This  view  has  obtained  numerous  supporters  in 
Germany,  and  in  Rosenstein's  work  it  is  adopted  without  dis- 
cussion. In  this  country  the  opposite  view  has  steadily  gained 
ground;  and  the  evidence  brought  forward  by  Johnson,  Wilks, 
and  Dickinson  appears  to  place  the  matter  beyond  reasonable 
doubt.  In  Germany,  too,  several  recent  writers,  amongst  whom 
are  Bartels,  Senator,  and  Ley  den,  have  adopted  this  view. 

Johnson  found  that  out  of  26  fatal  cases  of  enlarged  kidney, 
observed  by  himself,  there  was  dropsy  in  24,  or  92  per  cent. ; 
whereas  in  33  fatal  cases  of  contracted  kidney,  there  had  been 
dropsy  only  in  14,  or  42  per  cent.  He  pertinently  observes : 
"  If  all  the  contracted  Bright's  kidneys  have  passed  through  a 
previous  stage  of  enlargement,  it  is  difficult  to  understand  how 
it  can  happen  that  the  majority  of  those  patients  who  have 
reached  the  final  stage  of  renal  degeneration  should  escape  the 
dropsy  w^hich,  in  a  greater  or  less  degree,  troubles  nearly  all 
those  who  die  in  what  is  assumed  to  be  an  earlier  stage  of  the 
same  disease."  ^ 

Convulsions  and  secondary  inflammations  (pneumonia  and 
peritonitis)  are  more  frequent  wdth  the  smooth  kidney;  whereas 
hypertrophy  of  the  left  ventricle,  atheroma,  and  apoplex}^  are 
more  frequent  w^ith  the  granular  kidney. 

It  must,  of  course,  be  borne  in  mind  that  it  is  not  now  dis- 
puted that  the  large  white  kidney  does  sometimes  sufier  atro- 
phic changes,  and  that  in  exceptional  cases  it  may  at  length 
dwindle  to  very  small  dimensions.  Johnson  and  Dickinson  and 
Grainger  Stewart  adduce  several  examples  of  such  a  change,  but 
the}'  insist  that  even  in  its  further  stage  of  contraction  the 
smooth  white  kidney  is  still  distinguishable  from  the  granular 
red  kidney.  The  change  of  the  large  white  kidney  to  the 
atrophic  form  is  oftener  accompanied  by  a  similar  change  in  the 

1  Med.-Chir.  Trans.,  vol.  xlii.  p.  156. 


404  CHRONIC  bright's  disease. 

clinical  features;  the   symptoms   then    approach   in    character 
those  of  the  small  red  granular  kidney. 

The  symptoms  of  the  two  varieties  of  Bright's  disease  men- 
tioned above  are  not  yet  sufficiently  worked  out  to  enable  us 
always  to  prognosticate  from  the  clinical  signs  the  exact  lesion 
to  be  found  after  death.  Various  "  mixed  "  forms  are  occa- 
sionally met  with.  The  small  granular  kidney  is  subject  to 
attacks  of  acute  inflammation  and  congestion,  and  under  the 
influence  of  these  may  show  many  of  the  changes  of  the  large 
white  kidney.  Leyden  has  called  attention  to  cases  where  the 
symptoms  are  entirelj^  those  of  the  small  red  granular  kidney, 
yet  after  death  the  kidneys  are  found  large  and  pale.  The 
microscope  in  such  cases  shows  excess  of  interstitial  tissue,  as 
in  the  contracted  form,  but  combined,  it  may  be,  with  paren- 
chymatous changes. 

3.  Lardaceous  or  Waxy  Kidney. 

[So-called  Amyloid  Degeneration  of  Virchow ;  Depurative  disease 
of  Dickinson.) 

Most  pathologists  now  distinguish  the  waxy  or  lardaceous 
kidney  from  the  preceding  varieties  of  Bright's  kidney. 

Externally,  the  waxy  kidney  is  smooth,  or  sometimes  slightly 
roughened ;  the  capsule  peels  off  readily.  The  organ  is  usually 
enlarged,  sometimes,  however,  diminished  in  size.  On  section 
the  appearance  is  characteristic.  The  cortex  is  bloodless,  of  a 
w^hite  or  yellowish  color,  with  a  waxy,  smooth,  translucent  ap- 
pearance, resembling  bacon-rind.  The  organ  is  conspicuously 
tough  and  hard.  On  the  smooth  cut  surface,  little  appearance 
of  the  natural  secreting  structure  is  seen,  but  it  is  dotted  over 
with  bright  glancing  points  :  these  are  the  changed  Malpighian 
bodies.  The  cones  appear  unnaturally  red  and  distinct.  This 
description  answers  only  to  extreme  degrees ;  in  slighter  cases 
the  change  can  only  be  detected  by  the  use  of  reagents.^  When 
a  thin  section  thus  prepared  is  examined  under  the  microscope, 
the  w^axy  change  is  seen  to  affect  mainly  (sometimes  exclusively) 
the  bloodvessels.  The  Malpighian  corpuscles  are  the  parts 
earliest  attacked.  Without  reagents  they  appear  as  shining 
particles  vs^ith  thickened  capsules;  the  vascular  tufts  are  greatly 
swollen  and  give  the  characteristic  reaction.  In  advanced  cases, 
the  vasa  atferentia,  with  the  arteries  and  capillary  network  of 

^  For  naked  eye  purposes  the  liquor  iodi  of  the  British  Pharmacopoeia,  diluted 
with  water  until  it  has  the  color  of  brown  sherry,  is  recommended  as  a  convenient 
test  for  the  waxy  degeneration  (Dickinson).  The  iodine  imparts  to  the  affected 
portions  a  mahogany-brown  color,  whereas  the  parts  not  affected  take  a  merely 
yellowish  tinge.  For  microscopic  purposes  methyl-violet  is  the  best  test.  This 
reagent  colors  the  amyloid  pai'ts  red,  and  the  healthy  parts  blue. 


ANATOMICAL    TYPES  —  WAXY    KIDNEY.  405 

the  cortex,  and  even  the  vessels  oi'  the  pyrumids,  are  similarly 
chano-ed.  The  lumen  of  the  hloodvessels  is  much  diminished 
by  the  deposit. 

Dr.  Dickinson  has  described  a  morbidly  rigid  character  of  the 
renal  tubes,  when  the  kidney  is  examined  in  the  earlier  stages. 
Later  on,  the  epithelial  cells  of  the  uriniferous  tubes  are  com- 
monly withered,  often  infiltrated  with  fatty  molecules;  only 
rarely  are  they  the  seat  of  the  waxy  change,  but  the  basement 
membrane  of  the  tubes  is  frequently  affected.^  Hyaline  waxy 
casts  exist  in  some  of  the  tubules.  The  stroma  of  the  gland  is 
usually  increased  in  quantity  and  in  some  cases  to  an  extreme 
degree.  The  kidney,  then,  may  be  contracted  and  may  resem- 
ble in  microscopic  characters  the  small  red  granular  kidney. 

The  liver  and  spleen  are  usually  enlarged,  and  in  a  lardace- 
ous  state,  when  the  kidneys  are  so  afiected.  Of  77  cases  col- 
lected by  Eosenstein,  the  three  organs  together  were  affected  in 
48;  the  spleen  and  kidneys  in  20;  the  liver  and  kidneys  in  4; 
and  the  kidneys  alone  in  five  cases. 

The  chemical  nature  of  the  waxy  material  has  only  recently 
been  investigated.  Virchow  concluded  from  the  violet  <^olor 
produced  by  iodine  and  sulphuric  acid  that  it  belonged  to  the 
same  group  as  starch  and  cellulose,  which  likewise  yield  a  violet 
tint  with  the  same  reagents.  But  the  ultimate  analyses  of  C. 
Schmidt  and  Kekule  show  that  it  contains  nitrogen— rand  indeed 
as  much  as  15  per  cent.,  or  almost  exactly  the  same  proportion 
as  the  protein  compounds.  ISTeither  of  the  chemists  named  could 
produce  a  particle  of  sugar  from  it  by  boiling  with  dilute  sul- 
phuric acid.  It  further  resembled  albuminous  compounds,  in 
yielding  a  violet  color  with  the  cupropotassic  solution,  in  dis- 
solving completely  in  dilute  caustic  potash,  and  in  being  precipi- 
tated from  this  solution  in  white  flocks  by  acids. ^  The  propor- 
tion per  cent,  of  carbon,  hydrogen,  and  nitrogen,  found  by 
Kekule,  in  purified  waxy  matter,  from  an  exquisite  specimen  of 
lardaceous  spleen,  was :  C  53.58;  H  7.00;  N  15.4 — which  cor- 
responds closely  with  the  percentage  of  the  same  elements  in 
albumen.  Dickinson  considers  it  a  variety  of  fibrin e — but  dif- 
fering from  ordinar}^  fibrine  in  containing  about  one-fourth  less 
alkali  and  a  somewhat  larger  proportion  of  earthy  salts.  To 
call  it  "  amyloid "  is  simply  a  misnomer,  and  an  unfortunate 
one,  because  it  leads  to  confused  notions  as  to  the  existence  of 
some  connection  between  waxy  degeneration  and  the  (genuine) 
amyloid  substance  found  in  the  healthy  liver. 

1  Dr.  G.  Stewart  states  that,  occasionally,  epithelial  cells  are  found  on  the 
casts  in  the  urinary  deposit,  whicli  exhibit  the  peculiar  reaction  of  lardaceous 
matter. 

2  Friedreich  says  that  the  "amyloid  reaction"  (with  iodine  and  sulphuric 
acid)  was  obtained  by  him  in  perfection,  with  decolorized  fibrine  from  an  old 
luematocle. 


406 


CHRONIC    BRIGHT  S    DISEASE, 


Synopsis  of  Symptoms  and  Conditions  of  Origin. — Waxy  de- 
generation of  the  kidneys  always  comes  on  insidiously  and  in 
cachectic  persons  debilitated  by  some  preexisting  wasting  dis- 
ease. In  145  instances  collected  by  Fehr  it  coexisted  with  the 
following  disorders  ■} 

Pulmonary  tubercle   ........  43  cases. 

(complicated  with  caries  in  5  cases,  with  other  diseases 
in  6  cases.) 

Syphilis 34  " 

Caries  with  struma     .         .         .         .         .         .         .         .  26  " 

Empyema  with  fistula        .         .         .         .         .         .         .  4  " 

Dilated  bronchi  with  chronic  bronchitis     .         .         .         .  3  " 

Chronic  alcoholism    .         .         .         .         .         .         .         .  5  " 

Chronic  articular  rheumatism    .         .         .         .         .         .  2  " 

Cancer  (generally  of  the  uterus)          .         .         .         .         .  3  " 

Ague 4  " 

Chronic  nephritis  with  hydronephrosis       .         .         .         .  3  " 
Chronic  peritonitis,  scarlatina,  variola,  cirrhosis  of  the  liver, 

ovarian  tumor,  urethral  fistula  with  stricture  .         .  each  1  " 

Atonic  ulcers  of  the  foot    .         .         .         .         .         .         .  3  " 

Without  appreciable  cause          .         .         .         .         .         ".  9  " 

It. has  also  been  found  in  association  with  gout,  rickets,  various 
abdominal  tumors,  and  mercurial  intoxication. 

The  aspect  of  patients  with  waxy  kidneys  is  pale  and  cachec- 
tic, and  the  course  of  the  disease  is  essentially  chronic.  Dropsy 
is  present  in  the  majority  of  the  cases  (in  98  out  of  152  collected 
by  Fehr);  in  some  it  is  abundant  and  general,  in  others  slight 
and  partial.     Ursemic  symptoms  are  strikingly  infrequent. 

The  urine  in  the  earlier  stages  of  the  disease  is  markedly 
abundant — 60,  100,  or  even  200  ounces  per  day — and  Dr. 
Grainger  Stewart  has  pointed  out  the  important  fact  that  this 
polyuria  is  a  marked  feature  even  before  the  urine  becomes 
albuminous,  and  that  this  supplies  a  warning  of  the  approach- 
ing advent  of  this  form  of  Bright's  disease.  The  quantity  of 
albumen  is  at  first  small,  but  as  the  disease  advances  the  urine 
becomes  scantier,  the  proportion  of  albumen  very  great,  and  the 
specific  gravity  high.  The  color  of  the  urine  is  commonly 
pale,  and  it  allows  only  a  very  slight  deposit  to  subside.  This 
consists  of  casts  and  atrophied  renal  cells,  which  are  sometimes 
fatty.  Cells  resembling  those  of  pus  are  occasionally  found 
either  separate  or  aggregated  round  a  cast.  The  tube-casts  are 
usually  hyaline,  and  they  do  not  yield  a  brown  coloration  with 
iodine.     Epithelial  casts  are  also  sometimes  seen. 


'  A.  Fehr.  Ueber  die  Amyloide  Degeneration,  insbesondere  der  Nieren. 
Bern,  1867. 

-  Litten  has  described  cases  in  which  the  amyloid  change  had  proceeded  to  an 
advanced  stasie  without  albumen  appearing  in  the  urine  (Berl.  klin.  Wochensch., 
1878,  Nos.  22  and  23).  Strauss  has  found  that  in  such  cases  the  arterias  rectse  are 
the  parts  most  affected.     [See  Cornil  and  Brault,  loc.  cit.) 


GENERAL    COURSE    AND    SYMPTOMS.  407 

Miinch  detected  "  cor[)ora  amyhicea  "  in  the  urine  of  a  man 
with  lardaceous  kidney;  they  were  constantly  present,  and  were 
colored  violet  by  iodine  and  sulphuric  acid.' 

The  diagnosis  of  waxy  kidneys  rests  partly  on  the  coinci- 
dence of  a  pale  abundant  albuminous  urine  with  dropsy,  but 
chiefly  on  the  coexistence  or  preexistence  of  one  of  the  wasting 
diseases  of  which  waxy  kidneys  are  known  to  be  a  frequent 
complication,  namely,  phthisis,  caries,  long-continued  suppura- 
tion, and  constitutional  syphilis. 

GENERAL  COURSE  AND  SYMPTOMS  OF  CHRONIC  i3RIGHT'S 

DISEASE. 

Chronic  Bright's  disease,  in  the  great  majority  of  instances, 
begins  slowly,  imperceptibly.  It  is  rarely  detected  until  it  has 
already  existed  some  months — it  may  be,  years.  The  attention 
of  the  patient  is  at  length  awakened  by  the  gradual  failure  of 
his  strength,  the  increasing  pallor  or  sallowness  of  his  com- 
plexion, and  his  disinclination  to  exertion;  perhaps  his  sus- 
picions are  aroused  by  a  little  puffiness  under  the  eyes,  a  slight 
swelling  of  the  ankles  at  night,  unusually  frequent  calls  to  void 
urine,  or  shortness  of  breath. 

In  other  cases  these  premonitions  are  altogether  wanting, 
or  perhaps  they  pass  unheeded.  The  fatal  disorganization  in 
the  kidneys  proceeds  silently,  amid  apparent  health,  and  then 
suddenly  declares  itself  by  a  cerebral  hemorrhage,  a  fit  of  con- 
vulsions, rapid  coma,  amaurosis,  pulmonary  cedema,  or  a  violent 
inflammation. 

Or,  again,  the  disease  creeps  on  stealthil}^  in  the  wake  of  some 
preexisting  chronic  disorder — phthisis,  caries,  necrosis,  joint  dis- 
ease, constitutional  syphilis,  gout,  chronic  alcoholism,  or  ex- 
hausting suppuration. 

Or,  it  may  be  a  continuation  or  sequela  of  acute  Bright's 
disease. 

Lastly,  the  disease  may  lie  concealed  for  an  undetermined 
period,  and  then  reveal  itself  after  exposure  to  cold  or  a  fit  of 
intoxication,  in  the  guise  of  an  acute  attack — with  rapid  general 
anasarca  and  scanty  sanguineous  urine. 

The  principal  symptoms  of  the  disease  are :  albuminous  urine 
with  deposits  of  tube-casts  and  renal  epithelium;  dryness  of  the 
skin;  frequent  micturition,  especially  at  night;  dropsical  effu- 
sions into  the  subcutaneous  cellular  tissue,  serous  cavities,  or 
pulmonary  substance;  derangements  of  digestion:  progressive 
hydrsemia;  ursemic  phenomena  (headache,  amblyopia,  convul- 
sions, coma,  vomiting,  and  diarrhoea) ;  hypertrophy  of  the  left 

'  Cited  by  Parkes.     Composition  of  the  Urine,  p.  39J:. 


408  CHRONIC  bright's  disease. 

ventricle ;    secondary    inflammation    of    the    parenchymatous 
organs  and  serous  membranes. 

Few  cases  present  the  whole  of  these  symptoms ;  and  many 
present  only  two  or  three  of  them.  The  alterations  in  the  com- 
position of  the  urine  are  the  most  invariable;  they  are  also  the 
earliest  and  most  distinctive  symptoms ;  next  follow,  in  the 
order  of  constanc}',  the  deterioration  of  the  blood,  the  dropsical 
symptoms,  and  lastly  the  ursemic  and  inflammatory  incidents. 

The  disease  usually  pursues  an  interrupted  course.  It  is  sub- 
ject to  exacerbations  from  time  to  time,  with  intervals  of  quies- 
cence. The  exacerbations  are  generally  occasioned  b}'  exposure 
to  cold,  or  some  imprudence  in  diet  or  regimen ;  sometimes  no 
cause  can  be  assigned  for  their  occurrence.  They  are  marked 
by  pyrexia;  and  resemble,  often  closely,  an  attack  of  acute 
Bright's  disease.  The  intervals  of  quiescence  may  be  longer  or 
shorter,  some  weeks  or  months,  or  a  few  years;  the  remission  of 
the  symptoms  is  commonly  only  partial — the  main  features  of 
the  disease  persisting,  though  in  diminished  prominence.  Some- 
times, however,  the  remission  is  almost  complete,  and  there  re- 
mains little  except  the  albuminous  state  of  the  urine  to  attest 
the  existence  of  renal  mischief.  Nay,  even  this  ma}^,  in  very 
exceptional  cases,  be  absent,  and  the  nature  of  the  case  be  flrst 
revealed  at  the  autopsy. 

After  each  exacerbation  it  is  commonly  prett}^  evident  that 
the  disease  has  taken  a  step  in  advance,  and  assumed  a  fuller 
development;  and  that,  probably,  an  additional  portion  of  the 
kidney,  hitherto  spared  or  only  slightly  aflt'ected,  has  been 
disabled. 

But  whether  it  thus  proceed  per  saltayn  or  more  continuously, 
the  kidneys  are  at  length  so  deeply  injured,  and  their  depurative 
functions  so  far  abrogated,  that  life  falls  a  forfeit. 

The  immediate  cause  of  dissolution  is  various.  Sometimes 
the  sufferer  passes  peaceably  away  exhausted  by  anaemia,  bur- 
densome anasarca,  and  defective  digestion  of  food.  More  fre- 
quently the  final  scene  is  tumultuous.  Two  of  the  cases  to  be 
hereafter  related,  terminated  amid  a  pyrexial  exacerbation,  with 
formation  of  clots  in  the  heart.  About  one-third  of  the  subjects 
of  chronic  Bright's  disease  perish  by  ursemic  poisoning,  either 
in  the  form  of  coma  and  convulsions  or  irrepressible  vomiting 
and  diarrhoea.  A  considerable  number  die  from  the  dangerous 
situation,  or  intensit}'^,  of  the  dropsical  effusion — as  when  the 
lungs  or  glottis  are  invaded ;  or  death  comes  from  hydrothorax, 
or  from  gangrenous  erj^sipelas  set  up  in  the  tense  hydropic 
integuments  of  the  thighs,  legs,  or  genitals.  About  one-fifth 
die  by  secondary  pneumonia,  pericarditis,  or  double  pleurisy. 
The  remainder  are  cut  oft'  by  less  closely  connected  complica- 
tions— apoplexy,  cirrhosis,  phthisis,  intestinal  ulcerations,  etc. 


ILLUSTRATIVE    OASES.  40f> 

From  the  difficulty  of  asHigiiiug  the  exact  date  of  invasi(;ii, 
the  durcUio?)  of  the  disease  can  only  be  approximately  ascer- 
tained. Enough  is,  however,  known,  to  show  that  it  varies 
within  very  wide  limits.  The  usual  period  is  from  two  to  three 
years;  but  cases  may  end  in  six  months,  or  be  protracted  for 
four  or  five  years.  Exceptional  instances  have  been  recorded, 
in  which  patients  have  survived  10  years  (Johnson  and  Kuss- 
maul),  and  even  15  (Bright)  and  23  years  (Oppolzer).  The 
large  white  kidney  is  usually  fatal  much  more  quickly  than  the 
red  contracted  variety. 

The  following  abstracts  of  cases  will  serve  to  exhibit  the 
broad  features  of  the  disease,  in  its  more  familiar  aspects;  and 
prepare  the  way  for  a  more  detailed  consideration  of  the  symp- 
toms and  complications  : 

Case  1.  Chronic  Bright' s  disease,  latent  two  years,  without  dropsy — 
fatty  casts  and  cells  in  the  urine.  Death  by  urcemic  convulsions. — Mr.  V., 
a  solicitor,  of  temperate  habits,  set.  50.  Two  and  a  half  years  ago,  Mr. 
V.  suffered  from  sciatica,  for  which  he  was  under  medical  treatment. 
At  that  time  a  little  albumen  was  discovered  in  the  urine,  but  slight 
importance  was  attached  thereto.  Mr.  V.  speedily  recovered  from  his 
sciatica,  and  continued  in  good  health,  attending  to  his  business,  until 
four  months  ago,  when  he  became  subject  to  shortness  of  breath  and 
catarrhal  symptoms.  These  were  not  severe  enough  to  prevent  the 
patient  from  pursuing  his  occupation,  until  the  beginning  of  April,  1864, 
when  I  was  requested  to  see  the  case  with  the  late  Mr.  Mellor.  The 
symptoms  complained  of  were,  shortness  of  breath  on  exertion,  and 
failure  of  strength  ;  there  was  not  a  particle  of  oedema  (nor  had  there 
ever  been  any)  nor  ascites.  The  liver  and  spleen  were  not  enlarged  ; 
there  were  no  cardiac  murmurs ;  but  there  existed  slight  pra^cordial 
bulging,  and  the  heart's  apex  beat  in  the  vertical  line  of  the  nipple. 
The  shortness  of  breath  evidently  depended  on  pulmonary  oedema. 
The  countenance  was  pale  and  sallow,  and  the  body  spare,  but  not  con- 
spicuously emaciated.  The  urine  was  copious  (three  pints),  of  low 
density  (1012),  and  highly  albuminous  (3);  it  deposited  a  not  incon- 
siderable flourdike  sediment,  composed  of  casts  and  renal  epithelia, 
many  of  which  showed  abundant  signs  of  fatty  changes  {see  Fig.  51). 
The  casts  were  mostly  medium  sized ;  some  were  granular  and  opaque, 
as  at  a ;  others,  in  about  equal  numbers,  were  nearly  hyaline,  with  only 
very  faint  markings,  as  at  h.  AVithered  epithelia  studded  some  of  the 
casts,  or  lay  scattered  free  about  the  field.  Botryoidal  fat  masses  lay 
embedded  in  some  of  the  casts ;  other  casts  were  dotted  over  irregu-larly 
with  oily  particles.  Some  of  the  renal  cells  were  similarly  dotted  in 
their  interiors,  while  others  were  entirely  changed  into  round  agglomera- 
tions of  fat  molecules  (granular  corpuscles)  (c,  d').  A  few  sparse  blood- 
dsks  were  scattered  about. 

The  previous  history  was  singularly  barren  of  etiological  indications. 
The  patient's  mode  of  life  had  been  strictly  temperate ;  and  there  was 
no  evidence  of  repeated  exposure  to  cold,  nor  of  gout.  Father  and 
mother  died  at  the  age  of  forty-five — the  latter  of  consumption.     He 


410 


CHEONIC    BRIGHT'S    DISEASE, 


himself  had  enjoyed  remarkably  good  health,  until  the  invasion  of  his 
present  complaint. 

The  treatment  adopted  was :  dry-cupping  the  chest,  warm  bath  every 
second  day,  flannel  clothing,  cod-liver  oil,  and  iron.  The  dry-cupping 
removed  the  dyspnoea  at  once,  and  some  general  amendment  took  place 
in  the  course  of  the  ensuing  month. 

This  gentleman  continued  under  observation  until  his  death,  which 
took  place  in  three  months.  He  improved  for  a  while,  and  was  able  to 
go  to  Southport  for  a  fortnight,  where  he  derived  considerable  benefit. 
He  considered  himself  so  well  on  his  return,  that  he  believed  a  week  or 

Fig.  51. 


Casts  and  renal  cells  from  the  urine  of  Mr.  v.     a  a.  Gi-anular  opaque  casts  ;   6  6.  Hyaline  casts  ; 

c,  d.  Fatty  masses. 


two  would  complete  his  recovery.  He  resumed  his  usual  occupation, 
and,  for  a  week  or  two,  went  daily  to  his  office.  But  this  truce  was 
wholly  deceptive ;  the  condition  of  the  urine  never  improved.  It 
became  progressively  scantier  in  quantity — first  it  fell  to  40  ounces,  and 
then  to  30  ounces,  while  the  specific  gravity  continued  to  range  from 
1009  to  1011;  and  the  deposit  of  casts  became  more  and  more  opaque- 
granular,  and  less  and  less  fatty.  Emaciation  also  progressed,  and  the 
shortness  of  breath  returned,  and  could  no  longer  be  kept  under  by 
dry-cupping.  A  persistent  feverishness  began  to  prevail;  the  nights 
were  restless;  but  during  the  day  the  patient  was  dull,  almost  drowsy, 
and  indifferent.  Not  a  trace  of  oedema  appeared  throughout  the  com- 
plaint. The  hypertrophy  of  the  heart  became  progressively  more 
conspicuous. 

In  the  last  fortnight  of  life,  the  urine  became  very  scanty  (still  of  low 


ILLUSTRATIVE    CASES.  411 

density),  and  was  totally  suppressed  for  twenty-four  hours  before  death; 
vomiting  recurred  frequently,  with  utter  loathing  of  food,  and  especially 
of  animal  flesh.  The  sight  failed,  and  two  days  before  death  he  became 
completely  blind  for  more  than  half  an  hour.  The  restlessness  increased, 
accompanied  with  wandering  delirium,  the  tongue  became  dry,  the 
indifference  merged  into  drowsiness,  and,  after  a  fit  of  convulsions,  he 
died. 

The  general  course  and  symptoms  clearly  indicated  a  granular  con- 
tracting kidney;  but  the  friends  would  not  permit  a  post-mortem 
examination. 

Case  2.  Chronic  Bright' s  disease  from  intemperate  habits  —  sudden 
anasarca  after  a  wetting.  Death  from  pericarditis.  Granular  contracted 
kidneys. — W.  M.,  a  carter,  at.  40,  of  intemperate  habits,  was  admitted 
into  the  Royal  Infirmary,  March  1,  1858,  with  general  anasarca  and 
ascites.  He  had  followed  his  employment,  and  considered  himself  in 
good  health,  until  three  months  back,  when  he  got  a  severe  wetting,  and 
allowed  his  clothes  to  dry  on  him.  Soon  after  followed  lumbar  pains 
and  general  swelling  of  the  body.  On  admission  there  was  oedema  of 
the  face,  trunk,  and  extremities,  and  considerable  ascites.  The  skin  was 
dry;  the  urine,  of  low  specific  gravity,  contained  tube-casts,  but  no 
blood.  After  he  had  been  in  the  house  a  fortnight,  the  urine  became 
scanty,  and  intense  pericarditis  set  in,  which  proved  fatal  on  the  fifth 
day.  He  died  comatose  with  suppression  of  urine.  At  the  autopsy  the 
kidneys  were  found  granular  and  greatly  atrophied  ;  scarcely  any  corti- 
cal substance  remained.  Abundance  of  fibrinous  exudation  existed  in 
the  pericardium;  left  ventricle  immensely  hypertrophied — the  walls 
fully  one  inch  thick ;  the  valves  were  healthy. 

The  state  of  the  organs  after  death,  indicated  that  the  disease  had 
been  really  in  existence  for  a  hauch  longer  period  than  the  few  months 
during  which  symptoms  had  been  noted  by  the  patient. 

Case  3.  Chronic  Bright' s  disease  from  repeated  pregnancies — recurrent 
nrcemic  convulsions.  Granular  contracted  kidneys.  —  Mrs.  X.,  ast.  39, 
became  pregnant  of  her  sixth  child  in  the  autumn  of  1862.  About  the 
third  month,  unusual  frequency  of  micturition  at  night  was  observed, 
and  soon  after  slight  osdema  of  the  face  and  legs.  The  urine  was  found 
to  contain  albumen.  The  foetus  was  expelled  without  accident  at  the 
fifth  month,  and  a  few  days  after  all  the  oedema  disappeared ;  but  the 
urine  still  continued  albuminous.  I  first  saw  her  about  two  months 
after  the  miscarriage.  There  was  no  oedema  of  any  part.  The  urine 
was  of  low  density,  and  moderately  albuminous.  The  deposit  con- 
tained a  few  transparent  tube-casts,  some  of  which  showed  slight  evi- 
dences of  fatty  change ;  others  were  opaque,  and  studded  with  withered 
epithelia  (see  Fig.  52). 

The  patient  continued  under  observation  for  above  a  year,  and  died, 
at  length,  comatose,  after  repeated  attacks  of  convulsions.  Each  cata- 
menial  period  was  marked  by  great  nervous  excitement ;  and  on  several 
occasions  convulsions  took  place  at  these  periods,  accompanied  with  tem- 
porary amaurosis.      Severe  headache  was   a  very  constant  symptom, 


412 


CHRONIC    BRIGHT's    DISEASE 


especially  on  the  days  preceding  the  catamenial  periods.  After  death 
the  kidneys  were  found  granular  and  atrophied,  and  the  left  ventricle 
much  enlarged. 


Pig.  52. 


Transparent  and  opaque  casts  from  the  urine  of  Mrs.  X. 


Case  4.  Chronic  BrigMs  disease  from  intemperance  and  exposure  to 
cold — general  dropsy,  complicated  with  old  chronic  peritonitis.  Death  from 
syncojje.  Smooth  white  kidney,  beginning  to  contract.  Myriads  of  minute 
uric  acid  calculi  in  the  infundibula.- — J.  R.,  set.  48,  a  French  polisher, 
from  Oldham,  was  admitted  into  the  Royal  Infirmary,  April  4,  1864. 

There  was  great  ascites,  tense  oedema  of  the  lower  extremities,  with 
an  erysipelatous  state  of  the  integuments  of  the  upper  and  inner  parts 
of  the  thighs  and  scrotum  ;  oedema  also  of  the  arms  and  back  of  hands. 
The  heart  was  displaced  upwards,  and  much  enlarged ;  there  were  no 
cardiac  murmurs.  There  was  great  emaciation,  cough,  purulent  expec- 
toration, and  orthopnoea. 

The  urine  was  scanty,  dark-colored  from  blood,  highly  albuminous ; 
it  let  fall  an  abundant  chocolate-colored  deposit,  composed  of  "  blood- 
casts,"  "  granular  casts,"  and  "  epithelial  casts,"  with  abundance  of  free 
renal  epithelium  and  free  blood-disks.  Mixed  with  these  were  a  large 
number  of  irregularly  tailed  and  spindle-shaped  cells,  evidently  from 
the  pelvis  of  the  kidney  {see  Fig.  53). 

The  patient  stated  that  he  had  been  ailing  twenty  weeks  ;  the  symp- 
toms had  come  on  gradually.  The  swelling  had  first  appeared  in  the 
belly,  and  the  enlargement  of  the  abdomen  was  still  out  of  proportion 
to  the  general  dropsy.  His  habits  had  been  for  years  intemperate,  and 
he  was  often  exposed  to  chills,  in  suddenly  passing  from  his  warm  work- 


ILLUSTRATIVE    CASES. 


413 


shop  to  the  cold  open  air.     He  had,  however,  been  a  healthy  man,  and 
had  never  lost  a  day's  work  until  his  present  illness. 

He  went  on,  with  little  change  in  the  general  symptoms  and  urine, 
for  twenty-five  days,  when  he  became  feverish  and  delirious,  apparently 
from  cold,  taken  by  imprudently  exposing  himself  after  a  warm  l^ath. 
He  suddenly  fell  back  dead  on  April  27th,  as  the  nurse  was  shifting 
him  for  the  purpose  of  making  his  bed. 

Fig.  53. 


Blood-casts,  granular  casts,  blood-disks,  tailed  and  irregular  cells  from  the  pelvis  of  the  kidney — 
from  the  urine  of  J.  K. 


Autopsy,  24  hours  after  death.  There  was  a  good  deal  of  anasarca  of 
the  lower  limbs,  forearms,  and  hands.  An  enormous  quantity  of  serum 
escaped  from  the  peritoneal  cavity.  The  peritoneal  membrane,  in  its 
entire  extent,  was  thickened,  or,  rather,  it  was  invested  with  a  layer  of 
thin  adherent  fragile  false  membrane  of  a  pearly  translucency,  like  the 
hyaline  membrane  of  a  hydatid  sac.  The  intestines  were  sunk  on  the 
spine;  there  was  no  recent  peritonitis.  The  liver  was  covered  over 
with  a  rough  layer  of  hyaline  false  membrane,  which  evidently  em- 
braced it  tightly,  and  had  caused  it  to  shrink  much  below  its  natural 
bulk.  On  section  it  did  not  display  a  cirrhotic  structure.  The  spleen 
was  rather  large ;  its  capsule  thick  and  opaque.  The  kidneys  weighed 
together  eleven  ounces.  They  were  firm,  and  their  capsule  smooth,  but 
opaque  and  thickened.  The  capsule  peeled  off  with  only  moderate  ease, 
and  tore  the  subjacent  tissue  a  little.  The  surface  of  the  gland  was  yel- 
lowish-white picked  with  dead  white,  like  ivory.  On  section,  the  same 
appearance  was  seen  to  prevail  throughout  the  cortical  part.  The  cortex 
was,  if  anything,  below  its  normal  proportion.  The  pyramids  were  of  a 
faint  red  color,  not  unnatural  looking.     The  infundibula  were  somewhat 


414  CHRONIC   bright's  disease. 

dilated,  and  contained  (in  both  kidneys)  myriads  of  very  minute  yellow, 
uric  acid  calculi.  These  varied  in  size  from  a  pin's  head  to  an  almost 
microscopic  object ;  they  were  lumpy  and  irregular  in  shape.  The 
papillge  were  flattened,  some  of  them  almost  obliterated.  The  kidneys 
were  evidently  of  the  "  smooth  white"  species,  beginning  to  pass  into  a 
state  of  contraction.  The  heart  weighed  122  ounces  ;  the  left  ventricle 
was  enormously  hypertrophied  ;  its  walls  seven-eighths  of  an  inch  thick. 
The  right  ventricle  was  also  hypertrophied,  and  the  tricuspid  orifice 
somewhat  patulous.  All  the  valves  were  perfectly  healthy.  The  lungs 
were  strongly  compressed,  and  partially  airless  and  leathery  from  pleuritic 
effusion. 

PAKTICULAKS  OF  SYMPTOMS  AND  COMPLICATIONS. 

Urine. — The  urine  is  albuminous  to  most  varied  degrees.  It 
may  become  absolutely  solid  on  boiling,  or  it  may  contain  only 
the  minutest  traces  of  albumen,  even  in  confirmed  and  fatally 
tending  cases.  The  red  granular  kidney  is  accompanied  by 
but  a  small  amount  of  albumen  in  the  urine,  and  even  that 
may  in  rare  cases  be  present  only  at  certain  times  of  the  day.^ 
The  large  v^hite  kidney,  on  the  other  hand,  usually  causes  a 
large  amount  of  albumen  to  be  passed. 

Absolute  freedom  from  albumen,  even  for  short  intervals,  is  very  rare; 
I  am  convinced,  that  a  considerable  number  of  the  cases  so  reported,  are 
examples  of  imperfect  testing.  But  it  must  be  admitted  that  chronic 
degeneration  of  the  kidneys,  not  distinguishable  from  some  forms  of 
Bright's  disease,  does  exist  under  certain  circumstances,  without  albumi- 
nuria. The  following  example  of  scarlatinal  dropsy,  running  a  chronic 
course  and  ending  fatally,  without  albuminuria,  occurred  in  my  practice  : 

J.  K.,  set.  8,  was  admitted  into  the  Royal  Infirmary,  April,  1864, 
afilicted  with  general  anasarca.  She  had  had  scarlet  fever  four  months 
before,  and  during  convalescence  therefrom  (in  the  third  week),  was 
suddenly  seized  with  general  swelling  of  the  body,  which  has  continued 
since.  When  admitted,  she  presented  a  perfect  type  of  scarlatinal 
dropsy — universal  and  great  anasarca,  difficultly  pitting  on  pressure, 
puffy  pasty  face,  excessive  pallor  of  the  surface,  shortness  of  breath. 
On  examining  the  urine  not  a  particle  of  albumen  could  be  detected, 
nor  any  casts  or  other  renal  derivatives  ;  it  was  scanty  and  high-colored. 
The  skin  was  very  dry,  and  a  constant  degree  of  feverishness  existed. 

She  remained  under  observation  until  her  death,  four  weeks  after 
admission.  The  oedema  remained  stationary  ;  the  urine  was  repeatedly 
examined,  but  never  found  to  contain  albumen.  The  feverishness 
became  more  intense,  the  tongue  became  dry,  and  the  breath  very  short ; 
toward  the  close  there  was  diarrhoea,  which  helped  to  carry  her  off. 

Autopsy,  24  hours  after  death.  Several  deep  and  old  tuberculous 
ulcers  were  found  in  the  small  intestines.     A  few  nodules  of  tubercle, 

1  Dr.  Mahomed  maintains  that  in  the  pure  red  conti'acting  kidney,  no  albumen 
is  passed,  and  that  it  is  only  under  the  influence  of  an  intercurrent  affection  of  the 
renal  epithelium  that  the  albumen  makes  its  appearance. 


PARTICULARS    OB'    SYMPTOMS.  415 

as  big  as  peas,  were  grouped  under  the  peritoneum,  around  the  bases  of 
these  ulcers.  The  mesenteric  gkmds  were  enhirged  and  tubercuhjus. 
There  was  no  general  tuberculosis  of  the  peritoneum.  The  lunyn  con- 
tained a  few  old  tubercles  (of  no  great  size)  at  the  apices.  The  tuber- 
culous masses  were  throughout  old  and  inactive. 

Both  pleurae,  contained  a  large  quantity  of  fluid,  and  the  lungs  were 
much  compressed  thereby. 

The  liver  was  excessively  bloodless.     The  hearl  was  natural. 

The  kidneys  were  good  examples  of  the  "smooth  white"  Bright's 
kidney.  They  were  slightly  enlarged,  and  weighed  together  7  ounces. 
The  organs  were  limp,  their  surface  pale  and  smooth  ;  the  capsule  peeled 
off  readily.  The  most  curious  thing  about  them  was  the  existence  of 
certain  sharply  outlined  flat  depressions,  which  differed  from  the  re- 
mainder of  the  superficies.  The  surface  generally  was  of  a  character- 
istic fawn-color,  picked  with  dead  white ;  but  at  these  depressed  spots 
the  color  was  slate-gray,  and  contrasted  markedly,  by  its  blank,  gray 
aspect,  with  the  spotted  appearance  of  the  remainder.  It  was  evident 
that  atrophic  changes  were  beginning  to  take  place  at  these  spots.  On 
section,  the  kidneys  presented  the  usual  appearance  of  the  "smooth 
white"  kidney. 

There  was  no  information  as  to  the  state  of  the  urine  when  the  ana- 
sarca broke  out ;  but  for  a  month  preceding  death  it  was  free  from 
albumen,  though  the  general  symptoms,  and  the  state  of  the  kidneys 
after  death,  bore  evidence  of  the  existence  of  Bright's  disease.^ 

The  amount  of  albumen  lost  in  twenty-four  hours  varies 
commonly  from  45  to  300  grains.  Dr.  Parkes  observed  in  one 
instance  as  much  as  545  grains.  The  quantity  is  larger  during 
digestion  than  during  fasting;  it  may  be  twice  as  great.  It 
rises  and  falls  irregularly  in  the  course  of  the  disease — some- 
times diminishing  to  a  trace,  and  anon  increasing  to  an  intense 
impregnation. 

The  urine  is  generally  pale,  and  not  quite  clear.  It  deposits, 
on  standing,  an  amorphous  whitish  sediment,  of  renal  epithe- 
lium and  tube-casts.  It  sometimes  contains  blood — even  in 
quantity — though  generally  only  in  microscopic  proportion. 
When  there  is  intercurrent  pyrexia,  or  the  case  is  complicated 
with  phthisis  or  regurgitant  heart  disease,  the  urine  may  be 
high-colored,  and  turbid  from  lithates. 

The  quantity  of  urine  voided  per  day  varies  according  to  the 
type  of  the  disease,  and  the  presence  or  absence  of  pyrexia, 
sweating,  vomiting,  or  diarrhoea.  The  urine  is  throughout 
scanty  with  the  large  white  kidney;  I  have  known  it  not  to 
exceed  35  ounces  on  any  one  day  for  a  period  of  foar  months, 
and  to  be  under  20  ounces  for  three  successive  weeks,  and  under 
12  ounces  for  several  consecutive  days.    It  may  even  sink  to  one 

'  Hamilton,  out  of  sixty  cases  of  scarlatinal  dropsy  observed  by  him  in  Edin- 
burgh, encountered  two,  in  which  there  was  no  albuminuria. 


416  CHRONIC   bright's  disease. 

•or  two  ounces.  With  the  granular  contracthig  kidney,  the  urine 
is  abundant  (three  or  four  pints  a  day)  in  the  middle  periods  of 
the  disease ;  but  it  gradually  grows  scantier  towards  the  termina- 
tion; in  e?:ceptional  instances,  the  diuresis  is  profuse,  and  the 
urine  may  occasionally  amount  to  five  or  even  nine  pints  a 
day.^  These  larger  quantities  have  been  generally  observed 
.after  an  attack  of  ursemic  convulsions,  or  coincidently  with 
sudden  subsidence  of  dropsy. 

The  specific  gravity  is  low  when  the  urine  is  copious  (1006 
to  1015) ;  but  when  it  is  scanty,  the  sp.  gr,  may  rise  to  1030  or 
even  1040. 

The  reaction  of  the  urine  is  nearly  always  acid;  and,  not 
unfrequently,  it  deposits  uric  acid  and  oxalate  of  lime.  Occa- 
sionallj^  I  have  noted  it  alkaline  from  fixed  alkali,  and  twice 
ammoniacal  on  emission. 

The  renal  derivatives  (epithelium  and  tube-casts)  are  markedly 
scantier  in  the  chronic,  than  in  the  acute  forms  of  Bright's 
disease;  and  it  is  not  uncommon  for  them  to  be  altogether 
absent  for  limited  periods.  They  are,  however,  sometimes  dis- 
coverable when  the  urine  has  ceased  (temporarily)  to  be  albu- 
minous. The  appearances  of  the  discharged  epithelia  and  casts 
present  considerable  diversities,  which  supply  an  important 
insight  into  the  structural  changes  going  on  within  the  kidney. 
The  epithelial  cells  may  be  simply  withered ;  more  rarely  they 
.are  totally  disintegrated  into  an  amorphous  granular  debris;  in 
other  cases  they  contain  specks  of  oil,  or  they  may  even  be 
wholly  converted  into  an  agglomeration  of  oily  particles  so  as 
to  appear  identical  with  the  so-called  "  granular  "  or  "  Grluge's 
corpuscle."  The  casts  are  sometimes  similarly  speckled  with 
fat,  and  free  oily  dots  are  scattered  over  the  field.  Such  a  con- 
junction indicates  a  fatal  disorganization  of  the  organs — either 
large  fat  kidneys,  or  contracted  granular  ones.  But  the  casts 
most  commonly  seen  in  chronic  Bright's  disease  are  "small"  and 
"  large  "  hyaline  forms,  and  "  granular  "  opaque  ones.  Any  of 
these  may  have  a  few  wasted  epithelial  cells  strewed  over  them. 
Perfect  "  epithelial "  casts  are  rare  in  chronic  cases,  and  blood 
■casts  are  still  more  rare,  unless  there  be  concomitant  tricuspid 
regurgitation. 

When  intercurrent  exacerbations  of  the  renal  process,  with 
pyrexia,  arise,  there  will  be  found  (whatever  may  have  been  the 
previous  character  of  the  casts)  medium-sized  and  large  solid- 
looking,  pale-straw,  albuminous  casts  resembling  molten  glass 
[see  Fig.  55). 

Casts  of  these  diverse  appearances  may  be  discharged  by  the 

^  Christison,  pp.  174  and  186.  Pfeufer,  in  Henle  and  Pfeufer's  Zeitsch.,  Bd.  1. 
p.  58. 


PARTICULARS    OF    SYMPTOMS.  417 

same  individual,  even  during  the  Barae  day.  ConclusionH  as  to 
the  probable  state  of  the  kidney  can  only  be  drawn  from  the 
'prevailing  character  of  the  deposit,  and  not  from  one  or  two 
individual  casts  or  cells.  This  diversity  in  the  character  of  the 
casts  arises  from  the  different  condition  of  the  several  parts  of 
the  gland.  In  some  portions  the  tubuli  may  be  denuded  of 
their  epithelium,  and  the  exudation  thrown  into  them  is  dis- 
charged in  the  form  of  large  hyaline  casts ;  if  the  denuded  por- 
tions have  undergone  subsequent  contraction  the  casts  will  be 
small  and  hyaline.  Other  tubes,  clothed  or  partly  clothed  with 
epithelium,  shed  some  of  their  cells  with  the  contained  exudation, 
and  cause  the  appearance  in  the  urine  of  casts  more  or  less 
studded  with  epithelial  remnants.  The  longer  the  exudation  is 
retained  within  the  tubuli,  the  darker  and  more  granular  will 
it  appear,  when  discharged  as  casts ;  and  vice  versa,  casts  speedily 
discharged  are  commonly  hyaline.  Sometimes  casts  are  dark- 
ened by  the  coloring  matter  of  the  blood;  and  the  opaque  gran- 
ular ones  are  (sometimes  at  least)  composed  of  crushed  epithelial 
debris  moulded  into  the  form  of  the  tubuli.     See  Diagnosis. 

The  normal  solids  of  the  urine  are  all  diminished  in  chronic 
Bright's  disease.  The  urea,  is,  as  a  rule,  markedly  reduced — 
the  daily  quantity  averaging  only  about  100  grains ;  Frerichs 
has  observed  it  as  low  as  15  grains.^  There  is  no  corre- 
spondence, direct  or  inverse,  between  the  excretion  of  urea  and 
the  discharge  of  albumen.  "With  intercurrent  pyrexia  the 
excretion  of  urea  rises. 

The  changes  in  the  blood  are  the  complement  of  those  in  the 
urine.  The  blood  becomes  more  watery  and  poorer  in  albumen 
and  red  corpuscles.  On  the  other  hand,  urea,  uric  acid,  the 
extractive  matters  and  the  pale  corpuscles  accumulate  in  it. 
This  alteration  in  the  composition  of  the  blood  is  deeply  con- 
cerned in  the  production  of  the  more  prominent  features  of  the 
disease  —  the  aneemia,  dropsical  effusions,  ursemic  phenomena, 
and  secondary  inflammations. 

Dropsy  is  much  oftener  absent  in  the  chronic  than  in  the  acute 
form.  It  is  much  more  constant  with  the  smooth  large,  than 
with  the  granular  contracted  kidney.  Of  the  latter  class  pro- 
bably one-third  or  one-fourth  of  the  cases  run  their  entire  course 
without  dropsy.  The  effusion  begins  quite  as  often  in  the  feet 
and  legs  as  in  the  face ;  it  is  commonly  slight  and  partial,"  but 
sometimes  excessive  and  general.  When  the  heart  or  liver  is 
diseased,  ascites  and  oedema  of  the  legs  become  disproportion- 

1  Exceptions  occur  to  this  rule.  Mosler  mentions  a  case  of  Bright's  disease  in 
which  640  grains  of  urea  were  voided  in  one  day  (Archiv  d.  Vereins,  Bd.  xi.  S. 
513).  Schottin  found  creatine  and  creatinine  increased  in  the  urine  in  Bright's 
disease,  and  the  increase  was  observed  to  keep  pace  with  the  intensity  of  the 
uraamic  symptoms  (Archiv  der  Heilk.,  1860,  p.  417). 

27 


418  CHRONIC   bright's  disease. 

ately  prominent.  The  effusion  is  apt  to  change  its  seat  capri- 
ciousl}^;  and  it  comes  and  goes  from  time  to  time.  Sometimes 
it  disappears  totally  for  months,  and  then  returns  again.  More 
frequently,'  after  a  subsidence  of  the  general  dropsy,  oedema 
lingers  obstinately  in  one  or  two  places — over  the  flat  of  the 
tibise,  about  the  ankles,  beneath  the  eyelids,  under  the  conjunc- 
tival membrane,  or  about  the  genitals.  The  presence  or  absence 
of  dropsy,  generally,  but  by  no  means  always,  corresponds  with 
the  abundance  or  scantiness  of  the  urine;  but  it  has  no  relation 
to  the  amount  of  albumen. 

The  skin  is  usually  obstinately  dry,  perspiration  is  quite 
exceptional ;  and  when  it  occurs,  is  commonly  due  to  diapho- 
retic measures  of  treatment.  Profuse  sweating  does,  however, 
sometimes  take  place  spontaneously,  and  may  even  continue  for 
weeks.  In  one  such  case  under  my  care  an  abundant  crop  of 
pemphigus  vesicles  broke  out  on  the  surface.  The  integuments 
in  some  cases  are  excessively  pale  and  glossy,  but  more  com- 
monly they  are  sallow  and  rough.  There  is  little  or  no  tender- 
ness in  the  renal  region  in  the  chronic  cases,  and  the  frequency 
of  micturition  is  mostly  observed  at  night. 

Some  degree  of  bronchitis  is  almost  an  invariable  coincident  of 
Bright's  disease  both  in  the  acute  and  chronic  form. 

The  pulse  in  Bright's  disease  almost  invariably  reveals  high 
tension  of  the  arterial  system,  when  examined  either  by  the 
finger  or  by  the  sphygmograph.  The  high  tension  is  shown  not 
by  the  pulse  alone,  but  also  by  certain  auscultatory  signs, 
amongst  which  are  accentuation  of  the  aortic  second  sound,  and, 
as  was  pointed  out  by  the  late  Dr.  Sibson,^  a  reduplication  of 
the  first  sound  of  the  heart,  at  the  cardiac  apex.  Dr.  Broad- 
bent  and  Dr.  Mahomed  have  shown  that  such  high  tension  may 
precede  all  other  signs  of  Bright's  disease,  and  appropriate 
treatment  may  indeed  ward  off  the  more  serious  manifesta- 
tions. 

The  retina  in  Bright's  disease,  and  more  frequently  in  cases 
of  the  red  granular  kidney,  shows  various  changes,  some  of 
which  are  characteristic.  Dr.  Gowers^  first  described  a  narrow- 
ing of  the  retinal  arteries,  coincident  with  the  high  blood  pres- 
sure, the  narrowed  arteries  frequently  showing  a  white  border. 
Inflammation  of  the  optic  nerve,  and  diff"used  inflammation  of 
the  retina  are  met  with;  hemorrhages,  too,  are  frequently  seen 
and  are  most  frequently  "  flame-shaped,"  and  situated  in  the 
nerve  fibre  layer.  The  most  characteristic  lesion,  howevei*,  is  a 
peculiar  appearance  of  white  specks  arranged  in  radiations  from 
the  yellow  spot.  These  specks  are  due  to  degeneration  of  the 
nerve  fibres.     The  renal  affection  always  precedes  the  retinal 

1  Brit.  Med.  Journ.,  1877,  I.  p.  33.  ^  iby,^  igyg^  IJ.  p.  743. 


COMPLICATIONS.  419 

changes,  although  the  latter  have  in  many  cases  first  called  the 
attention  of  the  observer  to  the  possibility  of  Bright's  disease 
being  present.' 

Complications  and  Connection  with  Other  Diseases. — In 
long-standing  cases  hemorrhage  from  the  various  mucous  sur- 
faces sometimes  occurs.  A  little  haemoptysis  is  not  infrequent, 
and  occasionally  severe  epistaxis.  The  digestive  organs  are 
nearly  always  disturbed :  at  first  there  is  loss  of  appetite  and 
nausea ;  in  the  later  periods  frequent  or  even  uncontrollable 
vomiting  is  not  uncommon.  The  bowels  are  alternately  bound 
and  loose.  Severe  fitful  diarrhoea,  which  leaves  the  dropsy  un- 
diminished, is  not  uncommon,  especially  towards  the  close  of 
the  complaint.  Not  unfrequently,  anatomical  lesions  are  found 
in  the  intestines  which  explain  these  disturbances;  in  other  cases 
they  are  manifestly  ursemic.  Treitz  states  that  urea  is  discharged 
into  the  intestines  from  the  blood,  and  converted  into  carbonate 
of  ammonia,  which  acts  as  an  irritant  on  the  intestinal  mucous 
membrane.  The  more  palpable  changes  found  in  the  intes- 
tines are,  follicular  catarrh,  dysenteric  ulcers — sometimes  with 
sloughing  of  the  mucous  membrane.  In  220  cases  of  Bright's 
disease  collected  by  Treitz,  the  following  conditions  of  the  in- 
testines were  found  after  death.^ 

Hydrorrhoea  (intestines  filled  with  yellow-greenish  fluid)  .  80  times. 

Blennorrhcea  and  catarrh  .         .         .         .         .         .         .  60  " 

Croupous  and  ulceious  dysentery       .         .         .         .         .  19  " 

Sloughing .         .         .         .         .         .         .         .         .         .  12  " 

Sanguineous   contents   without  discoverable   source  of)  ,  ,( 
hemorrhage     ........        / 

Normal  feces      .         .         .         .         .         .         .         .         .  5  " 

Contents  of  intestines  undetermined.          .         .         .         .  11  " 

Secondary  inflammation  of  the  lungs,  endocardium,  peri- 
cardium, pleura,  peritoneum,  or  integuments,  may  break  out  at 
any  period  in  the  course  of  chronic  Bright's  disease.  The 
tendency  to  these  constitutes  one  of  the  principal  dangers  of  the 
complaint.  Cardiac  hypertrophy,  valvular  disease,  and  pulmo- 
nary tubercle  are  frequent  complications. 

The  following  table  exhibits  the  proportionate  frequency  with 
which  the  various  organs,  other  than  the  kidneys,  are  found 
afiected  in  Bright's  disease  generally.  It  contains  the  result  of 
406  autopsies,  contributed  as  follows  :  Bright,  100  ;  Christison, 
14;  Gregory,  37;  Martin-Solon,  8 ;  Rayer,  48;  Becquerel,  45; 
Bright  and  Barlow,  10;  Malmsteu,  9;  Frerichs,  21;  Rosen- 
stein,  114. 

'  See  J.  Clifford  Allbutt — On  the  use  of  the  Ophthalmoscope,  and  Gowers's 
Medical  Ophthalmoscopy. 

2  Prag.  Vierteljahrschr.,  1859. 


420 


CHRONIC    BRIGHT's    DISEASE 


Heart. 

Lungs. 

Pleura. 

Pericar- 
dium . 

Perito- 
neum. 

Liver. 

Spleen. 

Stomach  and 
Intestines. 

Brain. 

125  times  liy- 

115  times 

57  pleu- 

30 peri- 

4G peri- 

41 cir- 

58 chro- 

36 gastric 

14  san- 

pertrophy. 

oedema  of 
lungs. 

risy. 

carditis. 

tonitis. 

rhosis. 

nic  tu- 
mor. 

catarrh . 

guineous 
apo- 

54 times  with 

38  fatty 

85  catarrh  and 

plexy. 

valvular  dis- 

52 pneumo- 

liver. 

17  acute 

follicular  ul- 

ease. 

ma. 

splenic 
tumor. 

ceration     of 
Intestine. 

59  eifu- 
sion  of 

65  times  with- 

8 pulmonary 

serum 

out  valvular 

apoplexy. 

13   tuberculo- 

under 

disease. 

4  gangrene . 

3Y  tubercle. 

33  vesicular 
emphysema. 

sis  of  intes- 
tine. 

arach- 
noid- 

In  addition  there  were :  1  case  complicated  with  cancer  of  the  liver ;  4  cases  with 
cancer  of  the  pylorus  ;  2  typhoid  ulcers  of  intestines  ;  2  meningitis  :  1  meningeal 
tubercle ;  11  tumor  cerebri ;  3  abscess  of  lung  ;  11  nutmeg  liver  ;  3  lardaceoas  liver ; 
9  contraction  of  spleen  ;  3  diphtheritis  of  intestines  ;  1  softening  of  brain  ;  6  chronic 
arachnitis  ;    1  suppurative  meningitis. 

Bright' s  disease  and  phthisis.  This  complication  is  of  frequent 
occurrence.  In  the  great  majority  of  cases  the  pulmonary 
disease  is  advanced  to  its  later  stages  before  the  renal  symptoms 
make  their  appearance.  The  long- continued  discharge  of  pus 
from  the  lungs  gives  rise  at  length  to  waxy  changes  in  the 
kidneys,  v^^hich  are  followed  by  albuminuria  and  dropsical 
effusion.  This  is  no  doubt  the  usual  history  of  such  cases ;  but 
sometimes  the  renal  disease  precedes  the  pulmonary,  and  the 
changes  found  in  the  kidneys  after  death  are  not  invariably  of 
the  waxy  type. 

The  coexistence  of  two  fatally  tending  diseases  might  have 
been  expected  to  accelerate  the  inevitable  issue  ;  yet  most  cases 
of  this  class  have  an  exceedingly  chronic  course,  and  continue 
in  a  stagnant  condition  for  months  together.  The  onset  of 
albuminuria  often  determines  a  fall  of  the  temperature.^  In 
the  following  remarkable  instance,  the  pulmonary  disease 
(already  in  its  third  stage)  completely  retrograded,  and  was 
supplanted  by  the  renal  affection. 

M.  C,  set.  20,  a  meclianie,  was  admitted  into  the  Royal  Infirmary, 
October  27,  1863.  He  was  a  well-grown  young  man,  with  white  pallid 
features,  dry  skin,  heavy  eyes,  and  moderate  oedema  of  the  lower  ex- 
tremities. The  abdomen  was  enlarged  from  ascites,  and  the  integuments 
of  the  flanks  and  hypogastrium  were  cedematous ;  pulse  112,  regular, 
small ;  respirations  21 ;  tongue  moist,  slightly  furred.  The  state  of  the 
chest  on  admission  was  as  follows:  Diminished  expansion  over  both 
apices ;  but  more  on  the  right  side  than  the  left ;  conspicuous  depression 
of  the  right  infra-clavicular  region.     There  was  almost  complete  loss  of 


^See  Williams,  Brit.  Med.  Journ.,  1883,  II.  p.  1224. 


COMPLICATIONS. 


421 


resonance  on  the  right  side  as  low  as  the  second  interspace.  The  right 
upper  scapular  regions  were  also  dull  on  percussion.  Moist  crepitation 
and  cavernous  rhonchi  were  heard  beneath  the  clavicle  on  both  sides. 
Whispering  pectoriloquy  was  very  distinct  below  the  right  clavicle,  and 
present,  though  less  typically,  over  the  left  apex.  The  heart's  sounds 
were  natural ;  there  was  no  appreciable  hypertrophy.  The  expectora- 
tion was  copious,  airless,  purulent. 

The  urine  was  scanty,  araber-colored,  specific  gravity  1030,  intensely 
albuminous,  becoming  almost  solid  on  boiling.  A  slight  deposit  of 
withered  renal  epithelia  and  transparent  tube-casts,  without  any,  or  only 
very  faint,  signs  of  fatty  changes,  lay  at  the  bottom  of  the  glass. 

The  history  disclosed  perfect  health  until  ten  months  ago,  when  the 
patient  began  to  cough.  He  attributed  these  symptoms  to  cold  taken 
by  passing  out  into  the  cold  air  from  his  hot  work-room.  His  family  is 
tuberculous ;  a  sister  came  subsequently  under  my  care  with  phthisis. 
He  had  night  perspirations  six  months  ago.  Three  weeks  before  admis- 
sion the  ankles  began  to  swell ;  but  the  skin  had  been  dry  for  three 
months. 

Cod-liver  oil  and  iron  were  prescribed  ;  a  warm  bath  was  adminis- 
tered every  other  evening.  The  patient  constantly  kept  his  bed,  on 
account  of  the  swelling  in  his  legs  increasing  when  he  sat  up. 


Fig.  54. 


Transparent  hyaline  casts,  from  the  urine  of  M.  C  ,  on  January  29  (quiescent  period). 

For  a  period  of  two  months  I  was  unable  to  attend  at  the  Infirmary 
on  account  of  illness,  but  the  treatment  was  carried  on  during  my 
absence  without  alteration,  and  the  patient  kept  continuously  in  bed. 
"When  I  revisited  the  wards  in  January,  1865,  I  found  the  renal  symp- 
toms somewhat  advanced  ;  but  the  pulmonary  complaint  had  decidedly 


422 


CHRONIC    BRIGHT'S    DISEASE, 


receded.  The  urine  was  very  scanty,  varying  from  12  to  18  and  26 
ounces  a  day,  with  a  specific  gravity  ranging  from  1030  to  1034;  it 
often  deposited  amorphous  urates.  On  January  29th  the  urinary  de- 
posit corresponded  to  the  following  description  :  It  was  scanty,  and 
composed  of  atrophied  renal  cells,  with  a  few  excessively  transparent 
small  hyaline  casts,  some  of  which  were  speckled  with  albuminous 
granules  and  a  few  doubtful  oil  particles  (see  Fig.  54).  The  patient  at 
this  date  was  in  a  quiescent  state  and  free  from  fever. 

The  chest  complaint  was  now  altogether  in  the  background ;  there 
was  scarcely  any  expectoration,  and  the  physical  signs  indicated  a 
marked  amelioration.  The  depression  under  the  right  clavicle  was  less 
conspicuous,  and  the  movement  improved ;  the  percussion  sounds  were 
still  unaltered,  and  the  rhonchi  still  cavernous,  but  not  abundant ;  pulse 
varied  from  88  to  100 ;  respiration  from  20  to  22. 

During  February  the  urine  became  still  scantier  (12  to  20  ounces  a 
day),  with  a  density  ranging  from  1033  to  1041.  It  became  almost 
solid  on  boiling.     The  anasarca  increased,  and  extended  into  the  face 

Fig.  55. 


Massive  molten-looking  casts,  from  the  urine  of  M.  C,  February  28  (pyrexial  period). 

and  upper  limbs.      Occasional  vomiting  took  place,  and  the  appetite 
failed  entirely. 

In  the  last  week  of  February  the  patient  insisted  on  going  home. 
But  he  had  not  been  out  a  single  day  before  he  took  a  violent  cold, 
ushered  in  with  repeated  shiverings.  The  anasarca  increased  rapidly ; 
respiration  became  oppressed,  and  he  was  readmitted  three  days  later 
(February  26th)  in  the  following  state :  Great  general  dropsy,  the  urine 
almost  suppressed,  distressing  oppression  of  breathing.     A  compound 


COMPLICATIONS.  423 

jalap  powder  was  administered  ;  after  which  he  vomited  and  had  three 

loose  motions. 

On  the  following  day,  the  patient  was  very  thirsty  and  feverish  ; 
tongue  furred,  red  at  edges;  pulse  Ti'"^ ;  respiration  30;  cough  very 
distressing;  a  scanty  expectoration  of  nummular  purulent  sputa.  He 
complained  loudly  of  pains  in  the  abdomen,  chest,  and  back,  especially 
when  he  turned  in  bed.     There  was  great  restlessness. 

A  hot-air  bath  was  administered  with  the  effect  of  inducing  copious 
sweating,  and  reducing  the  oedema  somewhat. 

February  28. — Urine,  last  24  hours,  only  8  ounces  ;  it  was  intensely 
albuminous  and  deposited  urates.  The  renal  derivatives  presented 
totally  new  characters  ;  they  are  delineated  in  Fig.  55  ;  the  new  feature 
was  the  appearance  of  massive  molten-looking  casts  of  large  and  medium 
size.  Some  of  them  were  slightly  granular  in  spots ;  a  few  were  also 
sparsely  studded  with  epithelium;  but  there  were  no  proper  "epithelial 
casts ;"  there  was  neither  blood  nor  fat.  Some  of  the  large  casts  lay 
side  by  side  like  thick  logs,  and  appeared  as  if  split  in  a  longitudinal 
direction  at  their  extremities  (Fig.  do^. 

On  the  28th  the  patient  grew  feebler  and  more  restless ;  obstinate 
vomiting  set  in,  and  continued  nearly  till  death,  which  took  place  on 
the  morning  of  the  29th.  Only  two  ounces  of  urine  were  passed  in  the 
last  24  hours  of  life.  There  were  neitner  convulsions  nor  coma ;  and 
vision  continued  good  to  the  last. 

Autojisy,  30  hours  after  death.  The  right  lung  presented  an  exquisite 
example  of  retrograde  phthisis.  Half  a  dozen  small  cavities  were 
counted  in  the  upper  lobe — all  of  them  small,  varying  from  the  size  of 
a  pea  to  that  of  a  horse-bean — completely  lined  with  a  thick  pyogenic 
membrane.  Not  a  particle  of  tubercle  existed  around  these  cavities 
nor  in  any  part  of  this  lobe.  The  pulmonary  tissue  was  dark  and. 
leathery,  and  very  imperfectly  aerated.  The  right  apex  was  condensed, 
deeply  puckered,  and  traversed  in  various  directions  by  thick  white 
lines  of  cicatricial  tissue.  In  the  lower  lobe  of  the  same  lung,  a  vomica 
as  large  as  a  filbert  was  found  with  anfractuous  boundaries  composed  of 
tuberculous  matter.  ,  Small  masses  of  obsolete  tubercle — some  cretace- 
ous, others  putty-like — were  scattered  sparsely  through  the  lower  lobe. 

The  left  lung  was  crepitant  throughout.  The  upper  lobe  contained 
three  cavities — one  as  big  as  a  walnut — lined  with  pyogenic  membrane, 
and  not  surrounded  by  tubercle.  Small  nodules  of  tubercle  were  scat- 
tered through  the  upper  and  middle  lobes — some  cretaceous,  some 
putty-like,  others  unsoftened  and  crude.  The  inferior  lobe  of  the  left 
lung  was  highly  cedematous.  ]S"o  fluid  existed  in  either  pleura ;  but  old 
adhesions  pi-evailed  sparingly  on  both  sides. 

The  heart  was  of  the  usual  dimensions  ;  the  walls  of  the  left  ventricle 
were  thicker  than  was  to  be  expected  in  a  case  of  phthisis.  Both  sides 
were  filled  with  firm  bulky  clots  of  yellowish  fibrine,  which  closely 
adhered  to  the  inequalities  of  the  chamber,  and  sent  voluminous  pro- 
longations into  the  aorta  and  pulmonary  artery.  The  formation  and 
presence  of  these  clots  evidently  constituted  the  immediate  cause  of 
dissolution. 

The  liver  was  large  and  pale ;  the  hepatic  cells  well  formed,  and  not 
containing  more  than  the  usual  quantity  of  fat  molecules. 


424  CHRONIC  bright's  disease. 

The  spleen  was  larger  than  usual ;  its  texture  soft  and  natural. 

The  kidneys  weighed  together  23  ounces,  and  the  two  were  almost 
exactly  of  a  size.  They  furnished  a  typical  example  of  the  large, 
smooth,  mottled  kidney.  Their  surface  was  perfectly  smooth  ;  the  cap- 
sule, thin  and  transparent,  peeled  off  readily  without  tearing  the  glandular 
tissue.  The  prevailing  color  of  the  surface  was  fawn,  marbled  here  and 
there  with  red  ;  the  fawn  color  was  picked  with  dead  white,  as  in  ivory. 
The  organs  were  conspicuously  soft  and  flabby.  The  red  parts  of  the 
surface  showed  minute  spotty  and  sinuous  injection  of  the  superficial 
vessels. 

On  section,  the  cortex  was  found  greatly  hypertrophied  ;  it  stood  half 
or  three-quarters  of  an  inch  thick  on  the  broad  ends  of  the  cones.  It 
had  a  full  fawn  color,  with  broken  streaks  of  red  running  through  it  in 
diverging  lines,  from  the  bases  of  the  pyramids.  The  pyramids  were 
unusually  pale,  though  from  the  exsanguine  state  of  the  cortex,  they 
offered  a  pretty  strong  contrast  of  color  with  the  latter.  The  epithelial 
lining  of  the  convoluted  tubes  was  extensively  disorganized ;  both  cell 
and  nucleus  were  reduced  to  a  granular,  fatty  debris.  Scarcely  a  single 
cell  approaching  perfection  could  be  seen.  The  Malpighian  corpuscles 
were  not  altered  in  size ;  but  they  were  penetrated,  and  rendered  opaque, 
by  a  granular  material.  The  epithelium  of  the  straight  tubes  was  in 
much  better  preservation  ;  not  only  the  nuclei  could  be  seen,  but  the  out- 
lines of  the  cells  themselves.  A  considerable  quantity  of  spindle-shaped 
fibre-cells  were  found,  also  medium-sized,  massive-looking  casts — resem- 
bling those  found  in  the  urine  shortly  before  death. 

Two  things  appeared  singular  in  relation  to  these  kidneys,  namely, 
that  the  urine  should  contain  so  few  renal  derivatives  when  the  kidney 
contained  such  an  immense  quantity  in  a  disorganized  state ;  and  sec- 
ondly, that  this  disorganized  material  should  contain  fat  in  such  quantity 
without  there  having  been  any,  or  scarcely  any,  in  the  urinary  deposit. 
Perhaps  the  degeneration  of  the  epithelium  only  attained  this  maximum 
degree  in  that  last  intercurrent  febrile  attack  which  immediately  pre- 
ceded death  ;  if  so,  the  plugging  up  of  the  canals  of  the  pyramids  with  the 
massive  casts,  which  then  appeared  for  the  first  time  in  the  urine,  and 
which  may  have  been  the  determining  condition  of  the  suppression  of 
urine,  would  cause  the  absence  from  it  of  the  derivatives  of  the  con- 
voluted tubes. 

Bright's  Disease  and  Diseases  op  the  Heart  and  Vascular 
System. — The  connection  of  cardiac  disease  with  renal  disorder 
is  at  least  threefold. 

In  the  first  class  of  cases,  simple  hypertrophy  of  the  heart  and 
especially  of  the  left  ventricle,  is  found  without  valvular  incom- 
petency and  without  degeneration  of  the  muscular  fibres.  In  this 
class,  which  is  a  numerous  one,  as  the  table  at  p.  420  shows,  the 
cardiac  afiection  is  secondary  to  the  renal. 

Bright,  who  was  the  first  to  point  out  this  curious  coincidence,^  offered 
two  explanations  of  it — either,  that  the  altered  composition  of  the  blood 

1  Gny's  Hospital  Reports,  vol.  i.  p.  390. 


COMPLICATIONS.  425 

exercised  an  irregular  and  unwonted  stimulation  upon  the  muscular 
tissue  of  the  heart,  or  so  impeded  the  circulation  in  the  capillaries,  tliat 
a  greater  effort  of"  the  ventricle  was  required  to  drive  the  l>lood  through 
the  distant  minute  branches  of"  the  bhmdvesscls.  Traube'  explains  tlie 
occurrence  of  simple  cardiac  hypertrophy  in  chronic  Bright's  disease 
somewhat  differently.  In  his  experience  the  kidneys  in  these  cases  are 
markedly  atrophied.^  The  contraction  of  the  renal  tissue  involves  de- 
struction of  a  certain  amount  of  secreting  structure  and  a  diminution 
of  the  flow  of  blood  through  the  organs  by  reason  of  the  destruction 
of  bloodvessels.  Two  consequences  follow,  namely,  that  a  diminished 
amount  of  blood  passes  from  the  arterial  into  the  venous  system,  and 
that  a  less  quantity  of  fluid  is  withdrawn  from  the  arterial  system  for 
the  formation  of  urine.  Both  circumstances,  but  especially  the  second, 
operate  to  increase  the  tension  in  the  arterial  system,  and  consequently 
to  increase  the  resistance  which  the  left  ventricle  has  to  overcome  in  dis- 
charging its  contents.  The  hypertrophy  which  follows  is,  therefore, 
according  to  Traube,  a  conservative  or  compensating  change,  similar,  in 
the  mechanism  of  its  production,  to  that  induced  by  valvular  incom- 
petency or  aortic  constriction.  If  the  compensation  be  complete,  the 
heightened  tension  in  the  arterial  system  occasions  a  larger  transudation 
of  water  and  even  of  urea  and  other  urinary  solids,  through  the  kidneys, 
and  in  that  manner  materially  helps  to  stave  off  dropsical  effusion  and 
ursemic  symptoms.  But  should  some  additional  obstruction  to  the  cir- 
culation arise,  through  intercurrent  inflammation  of  the  bronchial  tubes, 
or  of  the  lungs,  pleura,  or  pericardium,  the  heart — enlarged  and  strength- 
ened through  it  be — no  longer  suffices  to  overcome  the  increased  resist- 
ance, and  dropsical  effusions  or  ursemia  speedily  make  their  appearance. 
Traube  adduces  some  apposite  examples  in  which  individuals  Avith  con- 
tracted kidneys  enjoyed  fair  health,  with  capability  of  exertion,  and 
continued  free  from  anasarca  and  ursemic  disturbance,  until  the  advent 
of  some  complication  disordered  the  balance  of  the  circulation,  and  then 
the  urine  became  scanty,  and  the  familiar  symptoms  of  renal  disease, 
previously  latent,  broke  forth  into  prominence. 

The  first  part  of  Traube's  argument,  that  the  granular  kidney  offers  a 
resistance  to  the  passage  of  arterial  blood,  has  been  proved  by  the  experi- 
ments of  Dickinson  and  Thoma  mentioned  above  (see  page  400);  but 
whether  this  obstruction  is  competent  to  produce  high  arterial  tension 
and  hypertrophy  of  the  heart  is  doubtful.  Experimental  evidence  is 
conflicting.  Ludwig  ligatured  the  renal  arteries  without  causing  high 
vascular  tension  or  hypertrophy  ;  Grawitz  and  Israel  narrowed  the  renal 
artery  and  removed  one  kidney,  but  while  they  did  so  cause  hyper- 
trophy of  the  heart,  they  assert  that  there  was  no  increased  tension. 
Lewinski,^  on  the  other  hand,  by  similar  experiments  obtained  both 

1  Ueber  den  Zusammenhang  von  Herz-  und  Nieren-Krankheiten,  p.  58. 

^  In  a  later  communication  Traube  brings  forward  evidence  to  sliow  that  hyper- 
tropliy  of  the  left  ventricle  is  an  almost  constant  concomitant  of  granular  and 
contracted  kidney.  In  77  cases  collected  by  him  from  various  sources,  the  left 
ventricle  was  found  hypertrophied  in  93  percent.  (Deutsche  Klinik,  1859,  p.  815). 
In  187  cases  of  granular  kidneys  collected  by  Dr.  Sibson  enlargement  of  the  left 
ventricle  (without  valvular  disease)  was  found  in  128. 

^  Zeitschr.  f.  klin.  Medic,  vol.  i.  p.  561. 


426  CHRONIC  bright's  disease. 

hypertrophy  and  increased  tension.  Bamberger  objects  to  the  first  part 
of  Traube's  view,  on  the  grounds  that  hypertrophy  of  the  heart  may  be 
found  when  there  is  no  destruction  of  the  bloodvessels  in  the  kidney,  or 
where  anastomoses  have  been  set  up,  as  was  shown  by  Thnma  in  the 
granular  kidney;  that  the  ligature  of  even  large  vascular  trunks  does 
not  cause  hypertrophy ;  and  that  this  view  does  not  apply  to  the  hyper- 
trophy of  the  right  ventricle,  which  is  also  found.  Bamberger^  adopts 
the  second  part  of  Traube's  view,  that  the  hypertrophy  is  produced  by 
an  increased  volume  of  the  blood  caused  by  deficient  excretion  of  fluids. 
In  the  granular  kidney,  where  the  urine  is  increased  in  quantity,  he 
believes  that  a  stage  of  deficient  excretion  has  preceded,  and  that  the 
present  hyperexcretion  is  merely  due  to  the  balance  of  the  system  being 
set  for  a  higher  grade. 

Dr.  George  Johnson  has  discovered  that  there  is  a  wide-spread  hyper- 
trophy of  the  muscular  walls  of  the  small  arteries  in  chronic  Bright's 
disease.  He  finds  it  not  only  in  the  arteries  of  the  kidneys,  but  also  in 
those  of  the  pia  mater,  the  skin,  the  intestines,  and  the  muscles.  He 
thus  explains  the  production  of  this  hypertrophy  and  the  manner  in 
which  it  reacts  on  the  left  ventricle :  "  In  consequence  of  the  degenera-- 
tion  of  the  kidneys  the  blood  is  morbidly  changed.  It  contains  urinary 
excreta,  and  it  is  deficient  in  some  of  its  own  normal  constituents.  It 
is  therefore  more  or  less  unsuited  to  nourish  the  tissues — more  or  less 
noxious  to  them.  The  minute  arteries  throughout  the  body  resist  the 
passage  of  this  abnormal  blood.  The  result  of  this  antagonism  of  forces 
is,  that  the  muscular  walls  of  the  arteries  and  those  of  the  ventricle  of 
the  heart  become  simultaneously  and  in  an  equal  degree  hypertrophied. 
The  persistent  overaction  of  the  muscular  tissue,  both  cardiac  and  arte- 
rial, is  found  registered  after  death  in  a  conspicuous  and  unmistakable 
hypertrophy." 

With  this  view  Dr.  Broadbent  in  the  main  agrees.  He  believes,  how- 
ever, that  the  vitiation  of  the  blood  precedes  the  kidney  change.  During 
this  prenephritic  stage,  high  tension  is  produced  by  the  contraction  of 
the  muscular  walls  of  the  arterioles,  but  by  appropriate  treatment  the 
kidney  mischief  may  be  avoided.  Dr.  Broadbent  shows  that  the  high 
tension,  even  in  confirmed  Bright's  disease,  is  not  permanent,  but  may 
temporarily  disappear  during  an  attack  of  pyrexia,  or  under  the  in- 
fluence of  nitrite  of  amyl,  which  relaxes  the  arterioles.  This  tends  to 
show  that  it  is  the  action  of  the  arterial  muscular  tissue  which  produces 
the  high  tension,  and  not  a  permanent  change,  such  as  the  capillary 
fibrosis  of  Gull  and  Sutton,  mentioned  below. 

Dr.  Galabin  believes  that  the  impediment  to  the  circulation  in  chronic 
Bright's  disease  lies  not  as  Dr.  Johnson  supposes  in  the  small  arteries,  but 
in  the  capillaries,  and  is  due  to  a  modification  of  the  capillary  attraction 
between  the  blood  and  the  walls  of  the  vessels,  and  that,  the  arterial 
pressure  being  thus  increased,  the  muscular  walls  of  the  heart  and  arteries 
are  both  hypertrophied  in  concert,  since  both  have  to  act  against  greater 
resistance. 

Sir  Wm.  Gull  and  Dr.  Sutton  have  advanced  a  novel  view  of  the 
pathology  of  granular  kidney  and  of  the  associated  changes  in  the  car- 

^  Yolkmann's  Samml.  klin.  Vortriige,  No.  173. 


COMPLICATIONS.  427 

dio-vascular  system.  They  announce  the  discovery  of  a  new  pathologi- 
cal change,  to  which  they  give  the  name  of  "  arterio-capillary  fibrosis." 
This  consists  in  the  deposit  of  a  "  hyalin-fibroid  "  material  in  the  fibrous 
coats  of  the  arterioles  and  capillaries.  This  change  may  prevail  exten- 
sively throughout  the  vascular  system — in  the  kidneys,  skin,  pia  mater, 
heart,  lungs,  spleen,  stomach,  and  retina.  In  its  nature  it  is  allied  to 
but  not  identical  with  senile  changes.  It  commonly  begins  in  the  kid- 
neys, but  it  may  begin  elsewhere ;  so  that  the  hyj)ertrophy  of  the  heart 
with  degeneration  of  the  bloodvessels  may  be  found  associated  with 
healthy  kidneys ;  and  that  when  atrophy  with  granulation  of  the  kid- 
neys exists  it  is  but  part  and  parcel  of  a  general  morbid  change.  The 
granular  form  of  Bright's  disease  is,  in  their  eyes,  essentially  an  example 
of  arterio-capillary  fibrosis.  This  view  has  been  strongly  supported  by 
Dr.  Mahomed  in  this  country,  and  by  Leyden  in  Germany. 

That  a  wide-spread  change  in  the  small  arteries  of  the  body  exists  in 
Bright's  disease  seems  now  well  established,  but  what  the  nature  of  that 
change  may  be  is  by  no  means  determined.  Thoma  showed  that  there 
was  thickening  of  the  subeudothelial  layer  of  the  small  arterioles,  cor- 
responding to  the  similar  lesion  found  in  syphilis  by  Huebner.  This 
condition  of  the  vessels,  so  far  at  least  as  the  kidney  is  concerned,  is 
generally  admitted.  Thoma  was  of  opinion  that  the  muscular  coat 
instead  of  being  hypertrophied  was  really  atrophied.  Ewald,  w^ho 
examined  the  vessels  of  the  pia  mater  covering  the  pons  Varolii  in  sixty- 
two  cases  of  Bright's  disease,  could  not  confirm  the  discovery  of  Gull 
and  Sutton.  The  appearances  described  by  them,  he  believed,  were  the 
results  of  the  reagents  employed.  On  the  other  hand,  he  confirmed  the 
opinion  of  Dr.  G.  Johnson  as  to  the  hypertrophy  of  the  muscular  coat, 
and  showed  further,  that  the  general  vascular  change  was  associated 
rather  with  interstitial  than  with  parenchymatous  changes  in  the  kidney. 

Senator  described  a  difference  in  the  character  of  the  hypertrophy 
according  as  the  kidney  change  began  in  the  epithelium  or  in  the  inter- 
stitial tissue.  In  the  former  case  dilatation  was  combined  with  hyper- 
trophy of  the  heart,  while  in  the  latter  the  hypertrophy  was  pure.  In 
the  first  case  he  believed  with  Dr.  G.  Johnson  that  the  retention  of 
excrementitious  matters  in  the  blood  caused  a  rise  of  arterial  tension 
and  consequent  hypertrophy ;  in  the  second  case  he  believed  the  hyper- 
trophy to  be  due  to  a  general  change  in  the  small  arteries.  His  differ- 
entiation of  the  two  kinds  of  cai'diac  enlargement  cannot,  however,  be 
sustained,  for  dilatation  of  the  left  ventricle  is  by  no  means  uncommon 
in  the  later  stages  of  granular  kidney,  and  is  due  to  weakening  of  the 
heart  muscle. 

BuhP  placed  the  cardiac  change  in  the  primary  position.  He  believed 
that  there  was  initially  a  myocarditis  which  caused  the  hypertrophy. 
Debove''  and  Letulle,  in  support  of  this  view,  have  shown  that  a  fibrous 
growth  between  the  muscular  fibres  of  the  left  ventricle  is  common  in 
Bright's  disease.  The  opinion  has  not  met  with  any  considerable  sup- 
port. 

These  views  have  been  sharply  criticised,  and.  are  still  in  dis- 
pute, but  the}^  unquestionably  bring  into  true  prominence  what 

1  Mittlaeiluna;en  a.,  d.  path.  Institut,  Munchen,  1878. 

2  Progres  Mklical,  1876,  No.  52. 


428  CHRONIC  bright's  disease. 

every  observer  of  extended  experience  in  eases  of  granular  kid- 
neys must  have  had  strongly  impressed  on  his  mind — namely, 
that  the  renal  disease  is  not  merely  a  local  affair,  but  that  it  is, 
rather,  a  part  of  a  widespread  tissue  degeneration  involving  the 
entire,  or  a  large,  portion  of  the  body. 

Of  the  various  forms  of  chronic  Bright's  disease,  the  red 
granular  kidney  is  the  most  frequently  accompanied  by  hyper- 
trophy of  the  heart;  less  frequently  does  the  association  occur 
with  the  large  white  kidney;  while  with  the  amyloid  kidney  the 
enlarged  left  ventricle  is  only  rarely  found. 

In  the  second  class  of  cases,  valvular  defects  and  their  conse- 
quences coexist  with  Bright's  disease.  Most  of  these  are  ex- 
amples of  endocarditis,  secondary  to  the  renal  disease.  But  in 
other  cases  the  cardiac  and  renal  aifections  arise  independently 
of  each  other,  and  depend  on  some  cause  common  to  both — as 
in  the  following  example: 

J.  H.,  set.  48,  was  admitted  into  the  Manchester  Royal  Infirmary, 
November  22,  1862.  He  had  right  hemiplegia ;  the  mental  faculties 
were  wholly  disordered;  there  was  gay  incoherence  and  insanity;  no 
fever.  The  heart's  apex  beat  in  the  fifth  interspace,  half  an  inch  out- 
side the  nipple  line ;  a  loud  systolic  bruit  was  audible  at  the  apex  and 
the  mid-sternal  base,  and  extended  up  the  aorta ;  a  faint  diastolic  bruit 
was  audible  over  the  second  right  cartilage.  The  urine  was  albuminous 
to  about  one-fifth ;  there  was  no  dropsy. 

The  patient  remained  in  the  Infirmary  a  month.  The  mental  de- 
rangement subsided  in  ten  days,  and  perfect  coherence  returned.  The 
other  symptoms  remained  unchanged.  He  returned  home;  and  in  a 
few  days  was  seized  with  coma,  which  proved  rapidly  fatal.  The  au- 
topsy revealed :  granular  red  kidneys  with  abundant  presence  of  fat ; 
cardiac  hypertrophy  with  fatty  degeneration  of  the  muscular  fibres ; 
extensive  disease  of  the  mitral  and  aortic  valves  with  atheromatous 
patches  on  the  aorta ;  two  old  apoplectic  clots  were  found  in  the  left 
hemisphere,  and  wide-spread  fatty  degeneration  of  the  arteries  existed 
at  the  base  of  the  brain. 

In  this  instance  fatty  degeneration  had  simultaneously  invaded  the 
heart,  the  brain,  and  the  kidneys,  and  produced  a  triple  series  of  symp- 
toms— -all  essentially  independent  of  each  other. 

The  third  class  of  cases  are  those  in  which  the  renal  disorder 
(congestion,  etc.)  is  secondary  and  subordinate  to  cardiac  disease. 
These  cases  have  already  been  fully  described  in  Chap.  I.  in 
connection  with  Congestion  of  the  Kidneys,  which  see. 

ITPv^EMIA. 

Certain  phenomena,  chiefly  affecting  the  nervo-muscular  sys- 
tem, arising  in  the  course  of  Bright's  disease,  have  been  attri- 
buted to  a  poisoned  state  of  the  blood,  from  the  retention  in  it 
of  excrementitious  matters  which  the  disabled  kidneys  are  unable 


UR--EMIA.  429 

properly  to  eliminate.  To  theise  phenomena  tlie  term  urcernic 
has  been  applied;  they  consist  of  twitchinf(s  and  convulsions  of 
the  voluntary  muscles,  headache,  drowsiness,  coma,  defects  of 
sight  and  hearing,  vomiting  and  diarrhfpa. 

It  is  a  marked  feature  of  urajmic  phenomena  that  those  which 
are  of  a  paralytic  nature  atfect  the  sensorium  and  the  special 
senses,  but  not  the  voluntary  muscles;  while  those  of  an  oppo- 
site kind  (exalted  irritability)  affect  the  voluntary  muscles,  but 
not  the  sensorium.  Delirium  is  rare,  while  coma  is  frequent; 
paralysis  of  the  limbs  is  scarcely  known  (unless  there  be  some 
anatomical  lesion  of  the  brain  superadded),  while  convulsions 
are  frequent. 

The  mode  in  which  ursemic  symptoms  enter  on  the  scene,  and 
the  forms  they  assume,  present  great  diversity. 

Generally  they  begin  insidiously  with  headache  or  vomiting, 
followed  by  heaviness,  indifference,  and  somnolence.  These 
premonitories  may  either  pass  away  in  a  few  days  without 
further  consequence,  or  they  may  be  succeeded  by  general  con- 
vulsions and  coma.  In  other  instances  the  patient  is  at  once 
struck  down  with  convulsions  or  insensibility  without  any  pre- 
vious warning,  or  he  becomes  suddenly  blind,  or  is  seized  with 
uncontrollable  vomiting. 

The  most  common  of  these  symptoms  is  headaclie;  few  indi- 
viduals with  degenerated  kidneys  altogether  escape  it.  A  sense 
of  heavy  weight  or  compression  is  complained  of  over  the  fore- 
head or  vertex.  Sometimes  the  pain  is  obstinately  fixed  at  the 
back  of  the  neck,  or  behind  the  orbits. 

The  defects  of  sight  consist  either  in  a  dimness  of  vision  (am- 
blyopia), which  comes  and  goes — objects  appearing  as  if  veiled 
in  mist — or  in  rapid  and  complete,  though  usually  temporary, 
blindness.  The  convulsive  seizures  are  often  accompanied 
with  temporary  loss  of  sight,  which  generally  persists  in  greater 
or  less  degree  for  a  certain  time  after  the  spasms  have  passed 
away. 

The  ophthalmoscope  reveals  no  organic  change  in  the  eye  in 
genuinely  ursemic  amblyopia:  it  is  a  purely  cerebral  pheno- 
menon, and  not  to  be  confounded  with  the  hemorrhagic  blind- 
ness (Retinitis  apoplectica),  which  is  also  not  uncommon  in 
Bright's  disease,  and  which  is  due,  as  V.  Graefe  has  shown,  to 
rupture  of  the  retinal  vessels.  In  this  latter  affection  (which  is 
in  no  sense  uraBmic)  the  loss  of  sight  is  seldom  complete,  but  is 
of  a  more  permanent  character.  The  production  of  it  is  prob- 
ably due  to  hypertrophy  of  the  left  ventricle  which  so  commonly 
accompanies  a  contracting  kidney,  and  the  increased  tension  in 
the  arterial  system  consequent  thereupon ;  it  is  an  occurrence  of 
the  same  order  as  the  sanguineous  apoplexy  to  which  the  same 
individuals  are  liable. 


430  CHRONIC  bright's  disease. 

TJrsemic  deafness  is  much  less  common  than  amblyopia,  and 
its  occurrence  is  highly  exceptional. 

UrEemic  convulsions  are  of  the  epileptic  type,  and,  as  a  rule, 
they  conform  strictly  to  that  type — being  accompanied  with 
complete  insensibility,  rolling  of  the  eyes,  biting  of  the  tongue, 
and  foaming  at  the  mouth.  The  paroxysms  commonly  leave 
the  patient  deeply  comatose. 

In  exceptional  instances  consciousness  is  not  wholly  lost.  In 
a  lady  under  my  care  the  paroxysms  coincided  with  the  cata- 
menial  periods ;  during  the  convulsions  the  patient  knew  the 
persons  about  her,  and  called  loudly  to  be  held  fast.  A  case  is 
related  by  Bright  in  which  the  spasms  at  first  resembled 
cramps  ;  these  were  followed  by  twitchings  of  the  hands,  arms, 
shoulders,  chest,  and  legs.  The  spasms  were  almost  constant, 
and  caused  a  somewhat  hurried  mode  of  expression  when  the 
patient  spoke,  but  the  intelligence  was  perfect.  As  the  case 
proceeded  the  spasms  became  more  and  more  severe,  with 
forcible  drawing  up  of  the  legs,  and  distortion  of  the  muscles 
of  the  face;  the  faculties  were  retained  to  the  last.^ 

An  attack  of  ursemic  convulsions  may  consist  of  only  a  single 
paroxysm :  more  frequently  there  occurs  a  succession  of  par- 
oxysms or  fits,  following  each  other  at  uncertain  intervals  of  a 
few  minutes  or  several  hours — the  patient  lying  during  the  re- 
missions in  a  state  of  profound  insensibility,  with  stertorous 
breathing,  pale  face,  and  dilated  pupils ;  or  in  deep  drowsiness, 
but  capable  of  being  partially  roused,  when  spoken  to  or  shaken. 

If  a  first  attack  does  not  prove  fatal,  it  may  recur  at  irregular 
intervals  of  weeks  or  months,  or  be  replaced  by  ursemic  symp- 
toms of  some  other  order.  Instead  of  the  clonic  convulsions 
tonic  spasms  are  occasionally  met  with,  afifecting  various  muscles. 
Occasionally,  too,  the  spasms  are  limited  to  special  groups  of 
muscles  and  may  occasionally  cause  a  condition  of  opisthotonus.^ 

Ursemic  coma  either  creeps  on  very  gradually,  passing  on,  in 
the  course  of  two  or  three  days,  into  complete  stupor;  or  it 
culminates  quickly — the  patient  falling  down,  as  if  in  apoplexy, 
perhaps  while  walking  in  the  street,  or  occupied  with  his  usual 
avocation.  Cases  of  this  class  when  there  is  no  anasarca,  and 
the  previous  state  of  the  urine  is  unknown,  are  very  liable  to  be 
confounded  with  apoplexy  or  with  narcotic  poisoning.  The 
following  instructive  illustrations  of  such  an  occurrence  are 
related  by  Mr.  Moore  and  Dr.  Richardson  : 

Case  1, — An  old  soldier,  named  Price,  was  received  into  Queen's 
Hospital,  Birmingham,  with  the  following  symptoms :  breathing  labori- 
ous and  sometimes  stertorous ;  when  left  alone  the  patient  passes  into  a 

1  Guy's  Hospital  Reports,  1840,  p.  139. 

2  Jaccoud.     Pathol.  Interne,  6th  edit.,  vol,  ii.  p.  439. 


UBMMIA.  431 

state  of  stupor,  answers  (juestions  seiifiibly  when  roused;  pupils  nrioder- 
ately  dilated,  indolently  sensitive  to  light. 

It  appeared  that  I'rice,  having  suffered  some  days  from  diarrhoia, 
went  into  a  druggist's  shop,  and  asked  for  a  pennyworth  of  tincture  of 
rhubarb.  The  shopman  added  to  this  dose  a  few  drops  from  another 
bottle,  and  Price  swalhjwed  the  whole  before  leaving  the  shop. 

Immediately  after  taking  the  above  dose  he  became  drowsy  and 
vomited  ;  at  the  suggestion  of  a  neighbor  he  returned  to  the  shop,  and 
asked  the  shopman  whether  he  had  given  him  laudanum.  The  latter 
told  him  that  he  had  put  in  a  few  drops  on  account  of  the  severity  of 
his  symptoms.  Upon  again  reaching  home  he  fell  asleep,  and  continued 
sleeping  unless  temporarily  roused.  In  this  state  he  was  taken  into 
hospital,  and  was  treated  as  a  case  of  opium  poisoning.  A  mustard 
emetic  was  ordered  immediately;  the  patient  was  kept  in  constant 
motion,  and  plied  with  strong  coffee.  He  improved  considerably  under 
the  treatment,  and  talked  over  his  old  campaigns  with  the  porter  who 
had  charge  of  him.  Next  day  he  relapsed  into  a  lethargic  state  ;  gal- 
vanism was  employed  without  benefit ;  he  was  now  walked  round  the 
hospital  garden  between  two  men,  and  strong  infusion  of  green  tea  was 
administered,  A  little  improvement  followed,  but  at  2.30  f.  m.  he  re- 
lapsed once  more,  and  the  breathing  became  more  oppressed.  As  long 
as  he  was  kept  moving  he  could  be  made  to  answer  questions ;  but  in 
the  course  of  the  afternoon  the  somnolence  deepened  in  spite  of  the 
treatment.  Ether  and  ammonia  were  applied  to  the  nostrils ;  cold  Avater 
was  dashed  over  the  face  and  neck  ;  but  at  8  p.  m.  the  drowsiness  had 
become  insuperable ;  the  stertor  augmented.  Mustard  poultices  were 
put  to  the  legs.  Venesection  was  tried,  but  when  four  ounces  of  blood 
had  flowed  the  pulse  became  thread-like,  and  it  was  thought  prudent  to 
desist.  The  coma  increased  in  intensity;  and  he  died  at  2.30  A.  M.,  44 
hours  after  admission,  and  102  hours  from  the  time  of  taking  the  dose. 

A  coroner's  inquest  was  held  on  the  case,  on  account  of  the  suspicion 
of  poisoning ;  but  the  results  of  the  post  mortem  went  to  exonerate  the 
druggist,  for  the  kidneys  were  found  granular  and  greatly  atrophied, 
and  the  urine  left  in  the  bladder  was  found  albuminous.  (J.  Moore, 
''London  Med.  Gaz.,"  1845,  p.  821.) 

Case  2. — A  woman,  aged  34  years,  who  was  given  to  drinking,  and 
had  recently  been  treated  for  primary  syphilis,  was  seized  on  November 
18,  1859,  with  rigors.  She  was  attended  by  a  neighboring  chemist,  who, 
on  November  22d,  gave  her  a  mixture  which,  he  said,  contained  dilute 
nitric  acid,  nitrate  of  potassa,  syrup  of  buckthorn,  sulphate  of  mag- 
nesia, and  water.  It  was  afterwards  proved  by  analysis  that  these  were 
the  constituent  parts  of  the  remaining  portion  of  the  mixture.  The 
medicine  was  sent  in  to  the  woman  on  the  evening  of  the  22d,  and  after 
taking  a  large  quantity  of  beef-tea,  she  swallowed  one  dose  of  mixture. 
Five  minutes  afterwards  she  became  hysterical  and  convulsed,  and  the 
friends  believing  the  woman  to  have  been  poisoned,  summoned  the  drug- 
gist, who  in  alarm  tried  to  get  her  to  take  some  ipecacuanha,  but  without 
avail.  In  the  course  of  the  night  a  medical  man  was  called  in ;  he 
found  the  woman  in  a  state  of  typhoid  coma,  wdth  pupils  slightly  dilated 
and   immovable,  and  the  body  at   times  convulsed — the  convulsions 


432  CHRONIC  bright's  disease. 

assuming  an  epileptiform  type.  Every  available  means  of  treatment 
was  carried  out,  but  the  coma  became  more  profound,  and  seventy  hours 
after  the  administration  of  the  mixture  above  mentioned,  death  closed 
the  scene.  By  the  coroner's  warrant  the  body  was  examined,  and  a 
chemical  inquiry  instituted.  The  brain  was  quite  healthy;  the  kidneys 
were  greatly  diseased — large,  flabby,  pale,  speckled,  soft,  and  greasy. 
The  analysis  disclosed  no  poison  of  any  sort.  (Richardson,  "  Clinical 
Essays,"  p.  135.) 

Case  3. — A  gentleman,  set.  63,  was  driving  in  an  open  chaise  through 
the  village  of  Mortlake,  in  1853 ;  he  was  observed  by  his  servant,  who 
was  by  his  side,  to  be  constantly  drowsy;  at  last  he  suddenly  seemed  to 
fall  into  a  helpless  state  and  dropped  from  the  chaise.  He  was  con- 
veyed into  a  house,  and  Dr.  Richardson  was  summoned.  Dr.  R.  found 
hitn  suffering  from  all  the  signs  of  narcotic  poisoning ;  the  pupils  were 
fixed  and  slightly  dilated.  Some  urine  was  withdrawn  from  the  bladder, 
and  found  to  be  largely  charged  with  albumen.  He  recovered  from  the 
attack ;  but  three  weeks  later  he  suffered  again  in  the  same  way,  and 
died  with  typhoid  coma — the  urine  being  altogether  suppressed  for  many 
hours  before  death,  and  having  been  albuminous  throughout  the  illness. 
(Richardson,  "Clinical  Essays,"  p.  141.) 

The  diagnosis  of  uraemic  coma  from  apoplexy  rests  on  the 
absence  (in  the  former)  of  paralysis,  and  the  partial  recovery  ot 
consciousness  between  the  convulsive  attacks — if  there  be  any. 
From  poisoning  by  opium,  renal  coma  is  distinguished  by  the 
dilated  or  semi-dilated  state  of  the  pupils,  and  by  the  occurrence 
of  remissions  in  the  insensibility.  From  ordinarj^  epilepsy  the 
diagnosis — apart  from  the  antecedent  history,  which,  if  known, 
suffices  to  indicate  the  nature  of  the  case — is  sometimes  difficult. 
The  incidents  of  the  seizures  are  often  identical,  even  to  the 
existence  of  an  aura.  In  uraemia  the  respiration  frequently 
assumes  the  Cheyne-Stokes  type.  As  a  rule,  ursemic  fits  want 
the  turgid  purplish  countenance  and  asphyxial  character  of  true 
epilepsy — the  face  in  ursemia  being  nearly  always  deadly  pale 
and  the  breathing  easy. 

Dr.  Richardson  relates  the  cases  of  two  children  poisoned  by 
belladonna  berries,  in  which  the  symptoms  closely  resembled 
ursemic  coma  sequential  to  scarlatina.  The  insensibility  was 
complete,  and  the  pupils  strongly  dilated.  The  examination  of 
the  vomited  matters  and  of  the  urine  furnishes,  in  such  cases, 
the  best  means  of  diagnosis. 

In  all  cases  of  convulsions  or  insensibility^  from  doubtful 
causes,  the  urine  should  be  forthwith  examined,  and,  if  neces- 
sary, withdrawn  by  catheter  for  that  purpose.  It  must  not,  of 
course,  be  forgotten,  that  sanguineous  apoplexy  is  a  not  unfre- 
quent  occurrence  in  chronic  Bright's  disease,  as  in  the  case  of 
J.  H,  before  related  (p.  428), 

Ursemic  coma  and  convulsions  may  prevail  separately;  but 


UR.EMIA.  433 

much  more  commonly  the  attacks  are  of  a  mixed  character,  and 
combine  several  or  all  the  phenomena  just  enumerated. 

As  a  rule,  both  the  quantity  of  urine  and  the  excretion  of 
urea  diminish  notably  at  the  period  immediately  preceding  a 
ursemic  attack.  Sometimes,  however,  very  great  scantiness  of 
urine,  or  even  total  suppression  (in  acute  Bright's  disease)  may 
exist  without  evoking  any  urfemic  symptoms.  In  a  case  of 
scarlatinal  dropsy  related  bj'^  Biermer,  complete  suppression  of 
urine  continued  for  5  days  without  uraemia;  then  followed  a 
further  period  of  41  days  in  which  urine  was  secreted,  but 
only  in  the  scantiest  proportions  (a  few  teaspoonfuls  a  dav), 
and  yet  no  uraemia.  At  the  end  of  this  second  period,  the  urine 
began  to  flow  abundantly  for  a  short  time,  and  then  again 
became  scanty.  Three  days  later  urseraic  coma  set  in,  followed 
by  convulsions,  which  proved  fatal. 

If  the  patient  recovers  from  the  coma,  various  mental  symp- 
toms, such  as  mania  or  melancholia,  may  show  themselves.^ 

Ursemic  vomiting  and  diarrhos.a  are  common  phenomena  of 
Bright's  disease.  The  vomiting  which  occurs  in  that  disease 
is  not,  of  course,  always  ursemic.  The  digestive  functions  are 
notably  impaired  throughout  the  complaint,  and  a  heavy  or 
indigestible  meal  may  at  any  time  be  rejected,  as  in  dyspeptic 
states  from  other  causes.  When  the  vomiting  is  really  uremic 
it  takes  place  without  reference  to  the  nature  of  the  contents 
of  the  stomach,  and  is  oft-repeated  or  uncontrollable;  the 
vomited  matter  is  a  watery  fluid,  either  distinctly  ammoniacal 
to  the  smell,  or  (if  acid)  evolving  ammonia  freely  when  caustic 
potash  is  added  thereto.  The  alvine  dejections  are  similarly 
characterized  when  due  to  the  same  cause. 

Paroxysms  of  dyspnoea  belong  to  the  least  frequent  forms  of 
ursemic  disturbance — if  indeed  such  attacks  have  at  any  time  a 
genuine  claim  to  the  designation  ursemic.  Fournier  cites.some 
cases  of  this  kind.  Only  the  following  somewhat  doubtful 
example  has  fallen  under  my  observation.  The  case  is  further 
remarkable  on  account  of  a  transitorily  ammoniacal  state  of  the 
urine. 

W.  R.  S.,  a  railway  porter,  set.  58,  was  admitted  into  the  Manchester 
Infirmary,  December  6,  1860.  He  was  a  stoutly  made  man,  who  had 
led  an  intemperate  life.  He  had  been  remarkably  healthy,  and  had 
scarcely  ever  lost  a  day's  work.  Two  months  before  admission,  his  legs 
began  to  swell  and  then  his  face.  He  continued  to  follow  his  employ- 
ment, though  with  difficulty,  until  two  days  before  his  admission. 

On  admission,  there  was  a  general  anasarca  of  moderate  degree ;  pallid 
features ;  enlarged  heart ;  copious  urine,  scantily  albuminous,  with  an 
abundant  deposit  of  granular  and  transparent  casts,  and  renal  epithe- 

'  Wagner.     Ziemssen's  Cvclopwd.,  Sd  edition. 
28  " 


434  CHRONIC  bright's  disease. 

Hum.  Neither  cast  nor  epithelium  showed  any  signs  of  fatty  degenera- 
tion. The  urine  was  sometimes  highly  acid  and  deposited  urates ;  at 
other  times  it  was  highly  ammoniacal  when  voided. 

On  December  27th  there  occurred  a  sudden  and  most  intense  paroxysm 
of  difficulty  of  breathing,  which  threatened  suffocation.  It  resembled 
in  every  respect  a  paroxysm  of  spasmodic  asthma,  and  lasted  five  hours. 
It  then  passed  away,  and  did  not  return  again  with  the  same  intensity ; 
though  slighter  attacks  of  a  similar  nature  occurred  on  two  other  occa- 
sions. 

On  January  11,  1861,  repeated  vomiting  took  place ;  there  was  also 
a  severe  cough  with  a  watery  expectoration  and  increasing  weakness. 
Somnolence  then  set  in,  which  gradually  passed  into  coma  and  proved 
fatal  in  three  days. 

The  autopsy  showed  hypertrophied  left  ventricle;  thickened  mitral 
valve ;  abundant  loose  vegetations  on  the  aortic  valves.  The  right 
auricle  and  ventricle  were  filled  with  a  firm  voluminous  yellow  fibrinous 
clot.  With  the  exception  of  dense  oedema  of  the  inferior  lobe  of  the 
left  lung,  the  respiratory  organs  presented  nothing  abnormal.  The  kid- 
neys were  found  granular  with  commencing  atrophy.  The  lower  urinary 
passages  were  quite  free  from  disease. 

The  ammoniacal  state  of  the  urine  persisted  in  this  patient  for  several 
successive  days ;  and  although  the  secretion  was  so  charged  with  car- 
bonate of  ammonia  that  it  had  a  pungent  smell,  and  eflTervesced  freely 
with  acids,  when  quite  fresh,  the  patient  experienced  no  pain  or  uneasi- 
ness about  the  bladder  nor  during  the  act  of  micturition — which  was 
not  unduly  frequent.  The  urine  contained  no  pus.  The  ammonia  in 
this  case  must  have  been  derived  directly  from  the  blood,  and  not  pro- 
duced, as  is  usual  in  ammoniacal  urines,  by  transformation  of  urea  in 
the  lower  urinary  passages.  Such  an  occurrence  betokened  a  free  gen- 
eration of  ammonia  in  the  blood ;  there  were  no  ursemic  symptoms  on 
the  days  when  the  urine  was  ammoniacal.  Did  the  elimination  of 
ammonia  by  the  kidneys  stave  off"  ursemic  accidents? 

Theories  of  Uraemia. — The  absence  of  anatomical  lesions  in 
the  brains  of  persons  who  die  of  ursemic  coma  and  convulsions 
has  constrained  pathologists  to  look  elsewhere  for  the  deter- 
mining cause ;  and  by  general  agreement  it  has  been  assumed 
that  that  cause  consists  in  certain  alterations  in  the  composition 
of  the  blood,  from  the  accumulation  in  it  of  the  excrementitious 
matters  (and  the  products  of  their  decomposition)  which,  in  the 
healthy  state,  are  removed  out  of  the  body  by  the  kidneys. 
The  blood  thus  poisoned  is  no  longer  capable  of  ministering  to 
the  tranquil  and  healthy  operations  of  the  nervo-muscular 
system,  and  engenders  the  various  abnormities  of  motion  and 
sense  which  have  just  been  described. 

But  pathologists  have  not.  been  content  with  this  general 
appreciation  of  the  matter,  and  have  striven  to  trace  the  pheno- 
mena to  the  presence  of  some  one,  or  the  derivatives  of  some 
one,  of  these  excrementitious  substances  in  the  blood.      It  will 


THEORIES    OF    UKiI<:MIA.  435 

not  be  necessary  in  a,  practical  work  like  the  present  to  enter 
fully  into  the  controversies — still  undecided — which  have  arisen 
on  this  subject.  It  will  suffice  to  indicate  the  different  views 
which  have  been  enunciated;  and  to  express  my  own  conviction, 
after  a  careful  review  of  the  observations  and  experinien 
adduced  on  all  hands,  that  none  of  the  exclusive  theories  of 
urseinia  has  made  good  its  claim  to  acceptance. 

Hammond  and  Richardson,  following  the  original  notion  of  Willis, 
contend  that  the  special  poison  in  these  cases  is  urea.' 

Frerichs  and  many  more  recent  observers  maintain,  on  the  other 
hand,  that  urea  is  itself  innocuous ;  that  it  may  be  injected  into  the 
veins  of  animals  without  detriment;  that  the  mischief  in  uraemia  arises 
from  the  transformation  of  the  urea  accumulated  in  the  blood  into  car- 
bonate of  ammonia,  and  that  the  carbonate  of  ammonia  so  generated  is 
the  immediate  excitant  of  the  nervous  symptoms.  Frerichs  upholds  this 
doctrine  by  two  propositions  which  he  claims  to  have  proved,  namely  : 
(1)  that  carbonate  of  ammonia  invariably  exists  in  the  blood  of  uremic 
patients,  and  in  that  of  animals  rendered  ursemic  by  removing  their 
kidneys,  and  can  even  be  discovered  in  their  expired  air ;  (2)  that  car- 
bonate of  ammonia  injected  into  the  veins  of  healthy  animals  produces 
fits  of  convulsions  with  intervening  pauses  of  coma,  exactly  resembling 
genuine  ursemic  attacks. 

Treitz  suggested  a  modification  of  this  view.  According  to  him,  urea 
is  not  transformed  in  the  bloodvessels,  but  is  first  vicariously  excreted 
into  the  alimentary  canal ;  here  it  is  speedily  converted  by  the  gastro- 
intestinal mucus  into  carbonate  of  ammonia ;  the  carbonate  of  ammonia 
so  formed  is  then  absorbed  into  the  blood,  and  pi'oduces  its  poisonous 
effects.  That  urea  is  excreted  by  the  intestines  in  Bright's  disease  is 
undoubted,  and  its  swift  conversion  into  carbonate  of  ammonia  has  been 
proved  experimentally  by  Bernard.  This  theory  of  Treitz  furnishes  at 
least  a  rational  explanation  of  ursemic  vomiting  and  diarrhoea,  and  of 
the  presence  of  the  volatile  alkali  in  the  matters  so  discharged. 

Since  the  theory  of  Frerichs  was  first  promulgated,  however,  it  has 
been  ascertained  by  Richardson  and  Hammond  that  ammonia  naturally 
exists  in  the  blood  of  healthy  animals ;  and  all  subsequent  observers 
(with  the  sole  exception  of  Petroff)  have  failed  to  discover  in  the  blood 
of  animals  rendered  ursemic  by  the  removal  of  their  kidneys  any  larger 
amount  of  ammonia  than  exists  in  the  healthy  state.  It  has  been  like- 
wise shown  that  other  substances  than  carbonate  of  ammonia  (chloride 
of  sodium,  urine,  and  urea)  are  capable,  when  injected  into  the  blood, 
of  evoking  comatose  and  convulsive  phenomena. 

The  subsequent  experiments  of  Oppler,  Schottin,  Perls,  and  Zalesky, 
seem  to  have  given  the  coup  de  grace  both  to  the  ammonia  and  to  the 
urea  theories  of  uraemia ;  and  they  indicate,  in  a  very  clear  manner,  that 

1  Kichter  found  that  solutions  of  urea  (30  per  cent.)  applied  directly  to  the 
sciatic  nerves  of  frogs,  produced  only  slight  and  uncertain  convulsions  of  the 
muscles,  far  inferior  to  tho^e  produced  by  a  solution  of  common  salt.  A  saturated 
solution  01  urea  produced  no  convulsions  at  all.  (F.  Eitcher,  Inaug.  Diss-.  : 
Erlangen,  1860.) 


436  CHRONIC  bright's  disease. 

ursemic  manifestations  depend  mainly  and  essentially  on  the  accumula- 
tion in  the  blood  and  tissues  of  those  primary  products  of  tissue-meta- 
morphosis (creatine,  creatinine,  and  other  extractives),  which,  in  a  later 
stage  of  histolysis,  are  converted  into  urea  and  uric  acid. 

Cuffer^  has  recently  asserted  that  the  ursemic  symptoms  are  due  to 
destruction  of  the  red  blood-corpuscles.  This  may  be  produced  by  the 
various  excrementitious  matters  which  accumulate  in  the  blood.  He 
does  not,  however,  reject  the  idea  that  the  symptoms  may,  in  certain 
cases,  be  due  to  spasm  of  the  cerebral  vessels,  which  view  Dr.  Hughlings 
Jackson  maintains. 

Feltz  and  Ritter^  have  asserted,  that  the  poisonous  substances  accu- 
mulated in  the  blood  are  not  the  above-mentioned  excrementitious 
matters,  but  potash  salts. 

Inquirers  into  the  theory  of  ursemia  may  be  reminded  of  the  remark- 
able absence  of  coma  and  convulsions — the  most  common  features  of 
clinical  urtemia  —  in  cases  of  obstructive  suppression  of  urine.  The 
cases  related  in  Chap.  I.,  Section  5,  of  the  present  work  show  incontest- 
ably  that  fatal  suppression  of  urine  from  blocking  up  the  ureters  gen- 
erally runs  its  course  without  the  usual  symptoms  of  uraemia  as  witnessed 
in  Bright's  disease. 

Dr.  0.  Rees  believes  that  the  tenuity  of  the  blood  in  Bright's  disease 
is  not  without  influence  in  the  production  of  the  cerebral  symptoms. 
Traube  still  further  developed  this  idea.  He  contended  that  the  watery 
state  of  the  blood  predisposes  to  interstitial  transudations ;  that  the 
hypertrophy  of  the  left  ventricle  increases  enormously  the  lateral  pres- 
sure in  the  arterial  system  ;  that  when,  from  any  cause,  a  still  further  in- 
crease in  the  tenuity  of  the  blood-serum  occurs,  serous  transudation  takes 
place  through  the  cerebral  capillaries,  and  gives  rise  to  oedema  of  the 
brain.  This  oedema  causes  compression  of  the  minute  cerebral  vessels, 
and  determines  an  anaemic  state  of  brain,  and  thereby  ursemic  convul- 
sions and  coma.  He  is  further  of  opinion  that  the  symptoms  are  of  a 
comatose  character  when  the  oedema  and  anseraia  affect  the  hemispheres, 
and  convulsive  when  the  central  ganglia  are  the  parts  affected. 

Jaccoud,  in  his  "Pathologic  Interne"  (vol.  ii.  p.  443,  6th  edition), 
asserts  that  the  ursemic  symptoms  may  in  various  cases  be  explained  by 
several  of  the  above-mentioned  conditions,  such  as  ammonia,  creatin- 
semia,  and  Traube's  oedema  and  ansemia  of  the  brain. 

Dr.  Mahomed,  again,  has  found  small  hemoirhages  in  the  cortex  of 
the  brain,  and  these  he  believes  to  be  the  cause  of  the  symptoms. 

l^one  of  these  theories,  considered  exclusively,  explains  satis- 
factorily the  protean  phenomena  of  urgemic  intoxication,  as 
v^itnessed  at  the  bedside.  The  subjects  of  Bright's  disease 
suffer  under  a  deep  abnormality  in  the  composition  of  the  blood 
and  tissues.  The  blood  is  unnaturally  watery  and  poor  in  albu- 
men ;  the  blood  and  tissues  are  unnaturally  charged  with  the 
primary  histolytic  products  (creatine,  extractives,  etc.),  and  with 
excrementitious  urinary  compounds  (urea  and  uric  acid,)  perhaps 

1  These  de  Paris,  1877. 

2  De  I'uremie  experimentale,  1881. 


DIAGNOSIS.  437 

also  with  the  products  of  the  decomposition  of  some  of  tliese. 
This  state  appears  to  induce  in  the  nervous  centres  a  proneness 
to  sudden  disorder  and  loss  of  equilibrium.  A  crisis  may  at 
any  moment  be  brought  about  by  an  exaltation  of  one  or  several 
of  the  disturbing  elements,  or  by  a  supervention  of  some  new 
and  different  cause  of  irritation  (hysteria,  menstruation).  A 
similar  hypersensitive  state  of  the  nervous  system  prevails 
naturally  in  early  life;  and  an  irritation  which  would  be  of  no 
moment  in  an  adult  (teething,  worms,  embarrassed  digestion, 
cutanous  irritation,  etc.),  suffices,  in  an  infant,  to  awaken  con- 
vulsive and  comatose  phenomena  closely  resembling  those  of 
uraemia. 

DIAGNOSIS  AND  PKOGNOSIS. 

Diagnosis. — Under  ordinary  circumstances,  chronic  B right's 
disease  presents  symptoms,  and  a  condition  of  urine,  so  charac- 
teristic that  it  can  scarcely  be  confounded  with  any  other 
malady.  Even  when  dropsy  is  absent,  a  persistently  albu- 
minous state  of  the  urine,  apart  from  heart  disease,  hardly 
belongs  to  any  other  condition. 

Temporary  albuminuria,  as  we  have  seen  (see  Congestion  of 
the  Kidneys),  occurs  occasionally  under  a  variety  of  inflamma- 
tory and  febrile  conditions,  without  structural  changes  of  any 
importance  in  the  kidneys.  These  cases  differ  from  Bright's 
disease  in  the  absence  of  dropsical  effusion;  the  quantity  of 
albumen  is  also  generally  very  small ;  the  excretion  of  urea  is 
natural  or  even  excessive  instead  of  being  diminished.  When 
defervescence  occurs,  it  is  speedily  followed  by  the  total  dis- 
appearance of  albumen. 

The  real  diagnostic  difficulties  lie :  («)  in  distinguishing 
acute  and  curable  cases  from  chronic  confirmed  ones;  (b)  in 
determining  the  precise  anatomical  changes  going  on  in  the 
kidneys ;  and  (c)  in  detecting  the  disease  when  it  is  encountered 
masked  by  an  inflammatory  complication  or  a  urjemic  paroxysm. 

(a)  The  case  must  be  considered  as  belonging  to  the  chronic 
and  confirmed  class,  if  the  disease  had  crept  on  insidiousW,  or 
if  it  be  found  complicated  with  chronic  phthisis,  caries,  long- 
continued  suppurations,  constitutional  syphilis,  enlarged  liver 
or  spleen,  or  hypertrophy  of  the  left  ventricle. 

If  the  invasion  have  been  acute,  and  the  albuminuria  still 
linger  after  the  abatement  of  the  febrile  symptoms,  time  be- 
comes a  necessary  element  in  the  diagnosis.  With  every  day 
that  passes  by  without  diminution  of  albumen  in  the  urine,  the 
fear  grows  stronger  that  the  disease  has  become  confirmed.  In 
such  a  conjuncture  the  character  of  the  urinary  deposit  supplies 
important  information.  If  the  epithelial  elements  and  blood 
corpuscles  continue  to  be  freely  discharged,  and  no,  or  only 


438  CHRONIC  bright's  disease. 

trifling,  signs  of  fatty  changes  appear  in  the  renal  derivatives, 
there  is  good  reason  for  confidence  that  the  observer  has  to  do 
v^ith  the  declining  stages  of  an  acute  disorder.  If,  on  the  other 
hand,  albumen  persist  in  considerable  quantity  after  the  pyrexia 
has  passed  away,  and  after  blood  has  ceased,  or  almost  ceased 
to  appear  in  the  urine,  it  is  probable  that  the  disease  has  lapsed 
into  a  chronic  and  confirmed  state;  and  if,  in  addition  to  these 
untoward  signs,  the  deposit  exhibit  marked  fatty  change,  that 
probability  becomes  a  certainty. 

It  must  not  be  forgotten  that  patients  suffering  from  chronic 
Bright's  disease  are  subject  to  occasional  febrile  exacerbations, 
in  which  the  urine  becomes  scanty,  high  colored,  and  perhaps 
bloody.  Such  exacerbations  are  liable  to  be  confounded  with 
the  acute  disorder ;  and  when  there  are  no  clear  indications  of 
chronicity  in  the  previous  history,  in  the  character  of  the  renal 
derivatives,  or  in  the  coexistence  of  complications,  the  difieren- 
tial  diagnosis  of  the  two  conditions  may  be  quite  impracticable 
until  the  lapse  of  time  shall  have  cleared  up  the  ambiguity. 

(b)  For  the  differential  diagnosis  of  the  difterent  types  of 
degeneration  going  on  in  the  kidneys,  the  reader  is  referred  to 
the  synopsis  of  distinctive  symptoms  furnished  in  the  first 
section  of  the  present  chapter. 

(c)  When  the  case  comes  under  notice  for  the  first  time, 
masked  by  an  inflammatory  complication  (pneumonia,  endo- 
or  peri-carditis,  etc.),  a  clew  to  the  primary  disorder  must  be 
sought  in  the  previous  history  of  the  case,  and  in  the  associated 
symptoms.  When  dropsy  (or  the  history  of  any)  is  absent,  the 
primary  renal  disease  is  apt  to  be  overlooked,  and  the  case  re- 
garded as  one  of  simple  inflammation  of  the  organ  affected  :  the 
urine  (in  such  cases)  assumes  a  febrile  character,  urea  becomes 
abundant  in  it,  and  its  specific  gravity  rules  high.  If,  under 
such  circumstances,  the  quantity  of  albumen  in  the  urine  be  but 
small,  the  absence  of  Bright's  disease  may  be  counted  on ;  but 
the  converse  deduction  is  not  invariably  warranted.  In  pneu- 
monia I  have  seen  the  urine  for  some  days  "  highly  "  albuminous 
without,  as  the  sequel  showed,  the  existence  of  any  renal  degen- 
eration. In  pleuris}'  and  pneumonia  (and  especially  the  former) 
the  simultaneous  implication  of  the  two  sides  furnishes  a  strong 
presumption  (supposing  the  urine  be  albuminous)  that  the 
inflammation  is  not  simple,  but  secondary  to  renal  disease. 
The  existence  of  cardiac  hypertrophy  without  valvular  disease, 
or  of  notable  anaemia,  also  favors  the  supposition  of  Bright's 
disease. 

The  differential  diagnosis  of  urEemic  coma  and  convulsions 
has  been  already  pointed  out  (see  p.  432). 

The  absence  of  casts  in  an  albuminous  urine  gives  no  security 
against  the  existence  of  renal  degeneration ;  indeed,  this  absence 


PROGNOSIS.  439 

is  generally  more  apparent  than  real.  When  the  casts  are  few 
in  number,  and  small,  they  subside  \'ery  ini[)ertectly,  and  are 
apt  to  escape  detection,  even  with  the  most  careful  examination.' 
In  other  cases  the  absence  of  casts  is  only  temporary;  and  I 
have  known  it  most  absolute  in  some  of  those  sad  hopless  cases, 
where  the  renal  disease  is  the  ultimate  upshot  of  an  intractable 
strumous  or  syphilitic  cachexia. 

Pkognosis. — The  prospects  of  a  patient  sufl'ering  from  con- 
firmed chronic  Bright's  disease  are  exceedingly  gloomy.  The 
textural  changes  in  the  kidneys  are  of  a  kind  that  do  not  admit 
of  reparation.  The  Malpighian  bodies  become  enveloped  in  an 
exudation  of  low  plastic  material,  of  which  the  only  tendency 
is  to  progressive  contraction,  and  the  tubuli  are  either  blocked 
up  with  fibrinous  plugs  or  shrivelled  into  useless  fibres.  The 
gland  is  not,  however,  equally  affected  throughout  all  its  parts, 
and  the  less  injured  portions  carry  on,  imperfectly,  the  depu- 
rative  functions.  As  the  sounder  portions  become  more  and 
more  involved — and  there  is  an  almost  inevitable,  though  slow, 
tendency  to  this — the  work  done  by  the  kidneys  grows  less  and 
less,  and  the  blood  is  more  and  more  contaminated  with 
histolytic  and  urinous  elements,  until  at  length  a  limit  is 
approached,  which  is  incompatible  with  life.  Long  before 
this  extreme  limit  is  reached,  however,  death  is  brought  about  in 
a  large  number  of  cases  by  one  or  other  of  the  numerous  compli- 
cations to  which  the  subjects  of  renal  degeneration  are  obnoxious. 

In  certain  more  favorable  cases  the  structural  changes  cease 
to  advance,  the  dropsical  effusions  (if  any  existed)  are  absorbed, 
and  the  condition  of  the  patient  remains  stationary,  perhaps  for 
months,  perhaps  for  years;  and  he  may  be  able,  with  proper 
precautions,  to  prolong  existence  in  fair  comfort,  and  even  to 
pursue  light  avocations,  for  very  considerable  periods  of  time. 
Cases  protracted  to  five  or  six  years  are  not  uncommon,  and  a 
few  instances  are  recorded  in  which  the  patient  has  survived  for 
ten,  fifteen,  or  even  twenty  years. ^     The  tenure  of  life  under 

^  Some  years  ago  I  was  consulted  by  a  medical  man  who  was  suffering  from 
persistent  albuminuria.  He  himself,  and  another  practitioner,  who  was  well 
accustomed  to  such  inquiries,  had  failed,  after  repeated  examinations,  to  detect  a 
single  cast  in  the  urine.  The  specimen  of  urine  sent  to  me  was  set  aside  for  twelve 
hours  in  an  appropriate  urine  glass.  At  the  end  of  that  period  I  could  not,  after 
long  searching,  discover  a  single  cast.  Next  daj^,  however,  the  urine  deposited  an 
abundant  sediment  of  very  minute  uric  acid  crj^stals.  On  again  searchiftg  for 
casts  I  found  several  without  difficulty — the  precipitation  of  the  uric  acid  had 
carried  them  down. 

^  The  protracted  survivorship  of  some  cases  of  chronic  Bright's  disease  is  very 
remarkable — in  some  rare  cases  the  disease  does  not  prove  fatal  at  all.  Possibly 
in  these  cashes  only  one  kidney  is  affected — its  fellow  remaining  sound.  That 
such  a  possibility  exists  may  be  inferred  not  onW  from  the  great  difference  in  the 
amount  of  disease  sometimes  found  in  the  two  kidnej's  after  death,  but  more 
certainly  from  such  a  case  as  that  of  Dr.  Moxon,  in  which  one  kidney  was  in  an 
advanced  stage  of  degeneration,  while  its  fellow  was  normal.  Path.  Soc.  Trans., 
V.  xix.  p.  268. 


440  CHRONIC  bright's  disease. 

these  circumstances  is  exceedingly  precarious,  and  an  imprudent 
indulgence  or  exposure  may  bring  life,  in  a  few  hours  or  days, 
to  the  verge  of  destruction;  the  patient  walks,  as  it  were,  on  a 
slumbering  volcano,  which  may  at  any  moment  awaken  its  fires 
with  a  fatal  explosion. 

But  although  the  final  prognosis  in  chronic  and  confirmed 
cases  is  thus  unfavorable,  the  immediate  prospects  of  the  patient 
may  be  fair,  and  there  is  still  hope  that  by  judicious  manage- 
ment amelioration  of  the  more  distressing  symptoms  may  be 
brought  about,  except  in  the  ultimate  stages  of  the  disease,  the 
dyspeptic  symptoms,  the  irregularities  of  the  bowels,  the  drop- 
sical accumulations,  and  the  bronchial  catarrh,  may  be  combated 
with  good  probability  of  success.  The  following  example  is  a 
striking  illustration  how  near  an  apparent  cure  the  subsidence 
of  the  symptoms  may  proceed,  even  from  an  apparently  desper- 
ate extremity. 

Mr.  B.,  a  designer,  of  sober  habits,  set.  38,  consulted  me,  May  9, 1862. 
He  was  suffering  from  great  and  general  anasarca  with  ascites.  The 
urine  was  scanty  and  intensely  albuminous.  There  was  an  abundant 
deposit  of  tube-casts  and  renal  epithelium.  These  structures  exhibited 
the  appearances  of  advanced  fatty  degeneration. 

The  patient  stated  that  the  dropsical  symptoms  had  existed  a  twelve- 
month, and  had  come  on  gradually — first  in  the  feet,  then  in  the  face — 
without  known  cause. 

A  fortnight  after,  I  was  requested  to  see  Mr.  B.  at  his  own  house.  He 
was  then  confined  to  bed ;  the  swellings  had  considerably  increased ;  the 
legs  were  tense,  and  incapable  of  being  moved  from  excessive  oedema ; 
the  peritoneal  effusion  was  very  great.  There  was  severe  dyspnoea 
(orthopnoea)  and  frequent  vomiting.     The  urine  was  almost  suppressed. 

Taking  into  consideration  the  state  of  the  urine,  the  character  of  the 
deposit,  and  the  time  the  disease  had  already  existed,  together  with  the 
threatening  gravity  of  the  general  symptoms,  it  seemed  hardly  possible 
that  the  patient  could  rally  to  anything  like  seeming  health  ;  and  yet 
this  took  place.  Compound  jalap  powders  were  administered  freely, 
and  blanket-baths  applied  daily.  Copious  watery  motions  were  pro- 
duced ;  the  legs  burst,  and  an  immense  quantity  of  fluid  drained  away. 
Improvement  went  on  steadily  in  the  course  of  the  ensuing  month  ;  in 
September  the  dropsy  and  ascites  had  nearly  disappeared.  A  speci- 
men of  urine  (of  which  the  flow  was  copious)  was  sent  to  me  at  this 
time  for  examination.  It  was  only  slightly  albuminous,  and  after  a 
diligent  search  I  failed  to  detect  any  casts. 

I  did  not  see  the  patient  after  this  ;  but  Mr.  Briggs,  with  whom  I  saw 
the  case,  informs  me  that  shortly  after,  the  patient  went  to  Wales,  where 
he  continued  to  improve  ;  the  oedema  disappeared  almost  entirely  ;  the 
appetite  returned  ;  and  the  strength  was  so  far  restored  that  he  was  able 
to  walk  fifteen  miles  in  a  day. 

On  his  return  to  town,  however,  the  dropsical  symptoms  reappeared 
and  increased  ;  and  a  cough  set  in,  accompanied  with  purulent  expecto- 


TREATMENT.  441 

ration.     The  pulmonary  symptoms  gradually  advanced,  and  he  died  in 
September,  1863,  about  eighteen  months  after  I  had  first  seen  him. 

The  favorable  and  unfavorable  signs  in  Brigbt's  disease  have 
relation  to  the  state  of  the  skin,  the  duration  of  the  disease,  the 
degree  of  deviation  of  the  urine  from  its  natural  quantity  and 
composition,  and  the  existence  of  complications. 

The  signs  which  indicate  that  an  unfavorable  terminatioji  is 
not  far  distant  are:  obstinate  dryness  of  the  skin,  the  urine, 
which  had  previously  been  abundant,  becoming  steadily  scantier 
without  proportionate  increase  in  the  specific  gravity,  evidence 
that  the  disease  has  existed  some  years,  repeated  recurrence  of 
urseraic  phenomena,  excessive  serous  effusion,  excessive  cardiac 
hypertrophy,  a  persistently  feverish  state.  Speedy  death  is 
indicated  by  the  breaking  forth  of  pneumonia  or  pericarditis,  by 
suppression  of  urine  or  uncontrollable  vomiting  and  diarrhcea. 
The  absence  of  these  signs  may  be  construed  in  a  favorable 
sense,  as  indicating  a  stationary  state,  and  the  probability  that 
the  final  issue  may  be  yet  far  distant. 

An  excessive  proportion  of  albumen  in  the  urine,  although  a 
proof  of  the  activity  of  the  morbid  process,  and  therefore  a  sign 
of  evil  augury,  is  not  necessarily  prophetic  of  impending  death. 
In  a  case  which  I  saw  with  Mr.  Stephens,  the  urine,  which  was 
examined  almost  daily,  became  constantly  solid  on  boiling,  for 
a  period  of  more  than  two  months.  During  this  period  the 
patient's  condition  was  stationary ;  he  was  then  seized  with 
pneumonia,  of  which  he  speedily  perished. 

TEEATMENT. 

In  the  management  of  cases  of  confirmed  Bright's  disease, 
three  objects  are  to  be  especially  aimed  at,  namely :  (a)  to 
hinder  the  further  extension  of  the  structural  changes  in  the 
kidneys;  (6)  to  prevent  the  occurrence  of  ursemic  and  inflam- 
matory accidents ;  and  (c)  to  palliate  or  remove  certain  threat- 
ening or  burdensome  symptoms — anaemia,  drops}^,  dyspeptic  and 
ursemic  phenomena,  etc. 

To  fulfil  the  first  indication,  the  conditions  under  which  the 
complaint  originated  must  be  carefully  traced  out,  and  the 
patient  removed  as  completely  as  possible  from  their  further 
influence.  In  some  instances  this  is  practicable ;  as  when  the 
disease  follows  intemperance  or  long-continued  exposure  to  wet 
and  cold.  In  protracted  suppurations,  necrosis,  caries,  joint 
disease  stricture  of  the  urethra,  and  old  vesical  inflammation, 
the  possibility  of  the  development  of  renal  degeneration  should 
be  kept  in  view  by  the  surgeon,  and  should  have  weight  in 
considering  the  propriety  of  operation.     In  all  such  afi:ections 


442  CHRONIC  bright's  disease. 

the  condition  of  the  urine  should  be  narrowly  watched ;  and 
the  first  appearance  of  albumen  is  a  warnino^  that  the  oppor- 
tunity for  operative  procedures  is  slipping  away,  never  to  return. 

There  is  no  evidence  that  local  counter-irritants  of  the  severer 
class — issues,  setons,  moxas,  etc. — applied  over  the  kidneys, 
exert  any  good  effect;  and  the  ulcerations  they  sometimes  leave 
are  apt  to  prove  intractable.  Mustard  poultices,  tincture  of 
iodine,  or  dry  cupping  may  be  applied  when  the  loins  are  the 
seat  of  aching  pain ;  but  their  influence  on  the  renal  lesion  is 
probably  nil  Blisters  are  inadmissible  on  account  of  their 
specific  irritating  effects  on  the  urinary  system. 

The  patient  should  be  habitually  clothed  in  flannel,  both 
limbs  and  trunk ;  and  the  activity  of  the  skin  should  be  further 
encouraged  by  moderate  walking  or  carriage  exercise,  and  the 
occasional  use  of  warm  baths  and  frictions  of  the  surface.  The 
bowels  should  be  opened  at  least  once  daily,  and  the  diet  should 
be  light  and  nutritious.  Milk  agrees  well  with  the  majority  of 
this  class  of  patients,  and  may  be  freely  partaken  of  ^  Two  or 
three  glass  of  claret  or  hock  daily,  or  a  glass  of  sound  beer,  are 
permissible :  but  the  stronger  wines  and  all  spirits  agree,  as  a 
rule,  badly,  and  should  not  be  allowed  unless  special  circum- 
stances imperatively  call  for  their  administration. 

Medicinal  agents  of  roborant  character  should  be  exhibited 
from  time  to  time — but  especially  preparations  of  iron.  I  have 
been  in  the  habit,  when  the  secondary  symptoms  or  complica- 
tions do  not  call  for  special  treatment,  of  contenting  myself  with 
giving  15  or  25  drops  of  the  muriated  tincture  of  iron  in  a  wine- 
glass of  water  night  and  morning — combined,  in  cases  of  stru- 
mous affinities,  with  cod-liver  oil.  If  the  tincture  produces 
headache  or  disturbs  digestion,  some  other  chalybeate  must  be 
substituted — the  citrate  of  iron,  citrate  of  iron  and  quinine,  the 
syrups  of  the  phosphate  or  the  iodide  of  iron,  the  saccharated 
carbonate  or  the  ferrum  redactum.  One  or  other  of  these  prep- 
arations can  generally  be  made  to  agree.  It  is  important  to 
get  patients  with  chronic  Bright's  disease  to  take  iron,  for  satu- 
ration of  the  system  with  iron  is  the  best  safeguard  against  the 
profound  ansemia  which  is  a  fertile  source  of  danger  and  distress 
to  the  sufferers  from  chronic  renal  degeneration. 

Are  there  any  medicinal  substances  capable  of  exercising 
control  over  the  quantity  of  the  albumen  lost  by  the  urine? 
Exact  observations  do  not  give  an  affirmative  answer  to  this 
question,  though  a  certain  reputation  has  been  gained  by  the 
mineral    acids   (especially    nitric   acid),   iodide    of    potassium, 

1  Drs.  Sparks  and  Bruce  have  made  some  very  careful  observations  on  the  in- 
fluence of  diet  in  a  case  of  Bright's  disease  They  found  that  an  absolute  milk 
diet,  or  an  absolute  non-nitrogenous  diet,  effected  a  reduction  in  the  amount  of 
albumen  excreted.     (Med.-Chir.  Trans.,  1879,  p.  243.) 


TREATMENT.  448 

tannin,  and  gallic  acid.  Dr.  Parkcs  exhibited  large  doses  of 
tannin  and  gallic  acid  without  producing  any  diminution  of 
albumen.  Ihavc  in  a  number  of  cases  used  gallic  acid  for  a 
period  of  many  weeks,  but  could  not  convince  myself  in  a  single 
instance  that  it  had  any  favorable  influence  on  the  excretion  of 
albumen,  and  in  some  instances  it  occasioned  serious  gastric 
disturbance.  Oppolzer  has  recommended  alum,  and  the  trials 
of  Heller  support  this  recommendation. 

Knowing  as  we  do  that  persons  with  albuminuria  and  degen- 
erated kidneys  may  preserve  passable  health  for  years,  so  long 
as  digestion  is  good,  the  blood  not  too  impoverished,  and  the 
complications  kept  away,  the  practitioner  is  not  justified  in 
interfering  too  actively  when  this  stationary  condition  is  main- 
tained :  he  should  confine  himself  to  the  enforcement  of  sound 
hj'gienic  rules  and  preventive  measures.  The  patient  should 
be  made  clearly  to  understand  that  he  is  to  treat  himself  as  a 
valetudinarian;  and  that  in  his  clothing,  his  eating,  drinking, 
exercise,  and  general  mode  of  life,  he  must  go  by  rule,  as  the 
sole  condition  of  not  running  the  most  fatal  risks. 

The  most  effective  means  of  combating  the  dropsical  effusions 
are  hydragogue  cathartics  and  warm  baths.  For  general  use 
there  is  no  hydragogue  superior  to  the  compound  jalap  powder 
with  an  additional  quantity  of  the  bitartrate.  It  acts  quickly, 
and  procures  two  or  three  copious  watery  stools.  The  objection 
to  its  use  is  the  nausea  and  sickness  which  it  too  often  occa- 
sions. To  diminish  this  inconvenience  as  much  as  possible,  an 
active  dose  (for  an  adult  giij  of  the  bitartrate,  and  15  or  20 
grains  of  jalap  corrected  with  a  little  ginger)  should  be  admin- 
istered early  in  the  morning  twice  or  thrice  a  week.  The  opera- 
tion of  the  medicine  passes  over  in  a  few  hours;  and  the  patient 
has  leisure  to  recruit  himself  in  the  intervals  between  the  doses. 
This  proceeding  is  less  harassing  than  to  keep  up  a  continued 
purgation  of  less  activity. 

Christison  speaks  in  high  terms  of  gamboge,  which  he  em- 
ployed in  doses  of  5  grains,  sometimes  7,  and  very  rarely  9 
grains,  every  second  day,  or  in  urgent  circumstances  ever}^  day. 
To  prevent  griping  he  had  it  finely  pulverized  with  half  a 
drachm  of  the  bitartrate  of  potash.  Colocynth,  scammony,  and 
elaterium  have  also  been  employed  on  divers  hands.  When 
the  serous  accumulation  is  very  threatening,  and  immediate 
effects  are  demanded,  no  remedy  is  superior  to  elaterium.  It 
may  be  given  in  doses  of  one-sixth  or  one-fourth  of  a  grain 
every  three  or  four  hours,  until  three  evacuations  have  been 
obtained.  In  the  employment  of  purgatives,  it  must  not  be 
overlooked  that  exhausting  diarrhoea  sometimes  occurs  spon- 
taneously in  the  later  periods  of  the  disease,  and  that  the  use  of. 
drastics  has  been  known  to  originate  this  untoward  symptom. 


444  chrojStic  bright's  disease. 

It  is  necessary,  therefore,  to  watch  the  action  of  these  evacuants^ 
and  to  desist  from  their  use  immediately  if  the  diarrhoea  shows 
signs  of  proving  intractable. 

Warm  baths  are  unquestionably  the  most  effective  of  dia- 
phoretics; they  not  only  promote  cutaneous  transpiration,  but 
often  increase  the  secretion  of  urine  at  the  same  time.  They 
may  be  applied  in  all  their  varied  modifications — warm  water^ 
hot  air,  steam,  or  the  blanket-bath.  When  one  modification 
fails  another  may  succeed.  Dr.  Liebermeister  describes  as 
highly  efiiective,  a  method  of  applying  the  warm  w^ater  bath,  by 
which  the  temperature  is  gradually  raised  after  the  bather  is 
immersed.  When  the  patient  first  enters  the  bath  the  tem- 
perature is  98° ;  it  is  then  gradually  raised  by  the  admission  of 
warm  water  to  108°  ;  after  remaining  in  the  bath  about  thirty- 
five  minutes,  the  patient  is  packed  in  hot  blankets.^ 

Unpleasant  consequences — headache,  suffusion  of  the  face, 
unwonted  heat  of  skin — occasionally  follow  the  use  of  warm 
baths,  and  may  even  necessitate  their  abandonment.  Generally 
these  inconveniences  diminish  as  the  remedy  is  repeated ;  and 
after  a  few  trials  patients  with  chronic  renal  disease  nearly 
always  take  their  baths  with  pleasure  as  well  as  with  advantage. 

Of  pharmaceutical  diaphoretics,  Dover's  powder,  James's 
powder,  and  liq.  ammon.  acetatis  have  been  chiefly  used  :  their 
effect  is  very  uncertain. 

Diuretics  are  of  much  inferior  value  to  purgatives ;  but  when 
there  exists  a  tendency  to  spontaneous  diarrhoea  or  to  severe 
gastric  derangements,  we  are  constrained  to  abandon  the  latter 
for  the  former.  My  experience  of  diuretics  has  not  given  me  a 
high  opinion  of  their  efficacy.  The  testimony  of  authors  on 
their  utility  is  conflicting.  In  judging  of  their  efifects,  some 
observers  have  not  sufficientlj^  considered  that  a  spontaneous 
diuresis  is  the  normal  outgoing  of  acute  renal  dropsy  tending 
to  recovery ;  and  that  in  patients  with  contracting  kidneys  pro- 
fuse diuresis  is  an  ordinary  feature  of  the  quiescent  state  in  the 
middle  periods  of  the  disorder,  so  that  when  the  urine  becomes 
scanty  and  the  dropsical  effusions  increase  during  an  intercurrent 
febrile  exacerbation,  the  reestablishment  of  the  diuresis  and  the 
diminution  of  the  anasarca  on  regaining  the  quiescent  condition,, 
must  not  be  too  hastily  attributed  to  the  diuretic  which  chanced 
to  be  employed  pending  the  pyrexial  attack. 

Diuretics  of  the  most  opposite  classes  have  been  recommended 
by  different  writers.  Bright,  who  had  but  slight  confidence  in 
diuretics,  was  in  the  habit  of  prescribing  uva  ursi  and  pyrola 
umbellata.  Christison  relied  on  digitalis  combined  with  cream 
of  tartar.     Rayer    perceived   little   advantage   in    digitalis    or 

1  Prag.  Vierteljahrschr. ,  1861. 


TREATMENT.  445 

squills,  and  he  found  that  thcj  almost  always,  at  length,  de- 
ranged the  stomach.  Horseradish  tea,'  according  to  his  experi- 
ence, offered  of  all  diuretics  the  best  chance  of  success.  Spruce 
beer  is  a  much  more  agreeable  beverage,  and  its  diuretic  action 
isprobably  not  inferior.  My  late  colleague,  Dr.  Kason  VV^ilkinson, 
has  repeatedly  obtained  good  results  from  its  use ;  and  on  his 
recommendation  I  have  tried  it  myself  in  a  number  oi"  cases, 
with  favorable  effects;  it  agrees  well  with  the  stomach,  and 
quenches  the  thirst  which  not  unfrequentl}'  torments  patients 
with  Bright's  disease,  more  effectually  than  any  beverage  I  know. 

Tincture  of  cantharides  was  employed  by  Dr.  Wells  in  seven 
<;ases,  in  doses  of  30,  50,  or  even  60  drops  per  day,  with  good 
effect  in  ffve.  Rayer  also  reports  well  of  it  in  some  cases  ;  but 
he  adds,  not  without  reason,  "  it  is  an  uncertain  remedy,  which 
might  be  dangerous  in  inexperienced  hands." 

I  have  tried  in  my  own  practice  dandelion,  broom-tops,  and 
belladonna  with  unsatisfactory  results. 

When  other  means  of  evacuating  the  dropsical  effusions  fail, 
and  the  tension  of  the  integuments  threatens  erythema  and 
gangrene,  there  is  yet  a  resource  in  acupuncture  or  incision  of 
the  legs.  This  rapid  and  easy  method  has  the  disadvantage 
that,  unless  stringent  precautions  are  taken,  the  punctures  are 
liable  to  become  the  focus  of  erysipelatous  inflammation,  which 
may  spread  and  pass  into  sphacelus,  with  disastrous  consequences. 
This  mishap  is  quite  as  likely  to  follow  needle  punctures  as  in- 
cisions, and  after  trial  of  both  plans,  I  prefer  the  latter.  One 
or  two  cuts  with  a  lancet  should  be  made  lengthwise  in  the  calf 
of  the  leg,  or  one  of  them  may  be  placed  on  the  dorsum  of  the 
foot.  The  incision  should  be  three-quarters  of  an  inch  long, 
a,nd  penetrate  fairly  into  the  subcutaneous  tissue.  To  prevent 
erysipelas  the  following  directions  should  be  carried  out ;  the 
incised  member  should  be  wrapped  in  hot,  moist  flannels  ;  these 
should  be  changed  frequently — at  first  every  two  or  three  hours. 
At  every  change,  the  legs,  and  especially  the  incised  parts,  should 
be  thoroughly  sponged  with  warm  water,  and  the  flannels  which 
are  soaked  with  the  discharge  should  be  completely  cleansed 
before  they  are  reapplied.  Traube  recommends  that  the  in- 
cisions be  frequently  washed  with  chlorine  water.  Under  such 
precautions  this  treatment  may  be  carried  out  with  safety — 
always  with  great  relief  at  the  time,  and  sometimes  with  pro- 
longed advantage. 

Dr.  Southey^  has   introduced,  in  the  form  of  his   capillary 

1  Half  an  ounce  of  the  root  infused  in  two  pints  of  water  was  the  dose  with  which 
Kayer  Ui-ually  began  ;  this  was  gradually  increased  to  one  or  one  and  a  half 
ounces.  The  dried  root  makes  a  less  acrid  infusion  than  the  fresh  root,  of  which  a 
smaller  quantity  must  be  used  (Mad.  d.  Keins,  ii.  p.  lb'2). 

2  Lancet,  1877,  I.  p.  649. 


446  CHRONIC  bright's  disease. 

drainage-tubes,  a  most  convenient  apparatus  for  removing  the 
watery  accumulations  in  the  limbs.  These  tubes  avoid  to  a 
great  extent  the  danger  of  erysipelas. 

In  those  cases  which  are  characterized  by  a  copious  flow  of 
urine  (contracting  kidney),  dropsical  effusions,  if  present  at  all, 
are  usually  slight  and.  partial;  and  their  existence  depends 
chiefly  on  the  watery  state  of  the  blood,  and  the  lowered  tonicity 
of  the  bloodvessels.  In  these  cases,  diuretic  and  cathartic 
remedies  avail  little  to  diminish  the  oedema ;  better  results  are 
obtained  by  ferruginous  preparations,  tonics,  and  mineral  acids. 
If  the  patient's  general  health  can  by  these  means  be  eifectu- 
ally  improved,  the  serous  effusions  will  not  delay  their  disappear- 
ance. It  is  in  cases  of  this  class  likewise  that  change  of  air,  or 
even  a  sea-voyage,  may  be  recommended,  provided  always  that 
the  disease  be  not  too  far  advanced. 

The  treatment  of  bronchial  catarrh  and  secondary  inflammations 
requires  to  be  undertaken  with  a  remembrance  of  the  primary 
mischief.  Mercury  and  bloodletting  are  inadmissible — the 
former  (unless  in  the  most  guarded  way)  on  account  of  the 
peculiar  susceptibility  of  the  system  in  Bright's  disease  to  mer- 
curial preparations,  the  latter  on  account  of  the  deep  undermin- 
ing of  the  strength  which  has  already  taken  place.  Internal 
antiphlogistics — aconite,  digitalis,  and  antimony — may  be  freely 
used;  also  external  applications — chloroform  epithems,  hot 
poultices,  dry  cupping,  etc. 

The  dyspeptic  symptoms  are  readily  controlled  in  the  early 
periods  by  a  careful  revision  of  the  diet,  and  the  use  of  vege- 
table bitters,  prussic  acid,  and  antacids.^  When  obstinate 
vomiting  of  ursemic  origin  sets  in,  it  is  very  difficult  to  subdue; 
creasote,  morphia,  and  ice  permitted  to  melt  in  the  mouth,  are 
the  most  effective  remedies.  Diarrhoea  of  similar  origin  must  be 
combated  by  acetate  of  lead,  opium,  and  sulphuric  acid. 

When  urcemic  symptoms  show  themselves,  renewed  efforts 
should  be  made  to  increase  the  flow  of  urine,  and  to  awaken  the 
vicarious  activity  of  the  skin  and  intestines  by  the  measures 
already  described.  If  coma  and  convulsions  have  actually  seized 
the  patient,  further  energetic  action  is  demanded.  Frerichs, 
consistently  wnth  his  view  that  carbonate  of  ammonia  is  the 
actual  poison  in  these  cases,  recommends  a  treatment  designed 
to  neutralize  the  free  ammonia,  and  reduce  it  to  a  state  of  innoc- 
uous combination.  He  directs  chlorine  (which  may  be  inhaled 
in  the  gaseous  state  or  taken  dissolved  in  water)  and  the  vege- 
table acids  to  be  taken  internally,  the  body  to  be  sponged  with 
vinegar,  and  vinegar  to  be  used  in  injections. 

1  Dr.  Lauder  Brunton  has  found  arsenic  of  great  service  in  cases  of  Bright's  dis- 
ease, where  dyspeptic  symptoms  are  prominent. 


TREATMENT.  447 

During  the  convulsive  paroxysm,  chloroform  inhalation  is  the 
most  prompt  and  ready  means  of  controlling^  the  spasms.  When 
the  uniemic  paroxysm  hegins  with  drowsiness  and  gradually 
passes  on  to  insensibility,  or  when  convulsions  occur  only  as 
breaks  in  a  continuously  comatose  condition,  chloroform  aftbrds 
no  prospect  of  relief.  Chloral,  especially  if  administered  by  the 
rectum,  is  of  great  service  in  controlling  the  convulsions. 

At  the  time  when  Bright,  Christison,  and  liayer  puljlished  on 
this  subject,  everything  in  the  shape  of  an  apoplectic  or  con- 
vulsive seizure  was  the  signal  for  immediate  and  copious  vene- 
section; it  is  not  surprising,  therefore,  to  find  in  the  cases  they 
recount  that  free  and  repeated  bleedings  are  almost  invariably 
chronicled  in  the  next  sentence  to  that  announcing  the  advent 
of  the  uraemic  paroxysm.  Dr.  Richardson  has  recently  advo- 
cated the  same  plan.  The  immediate  effect  is,  unquestionably, 
in  a  large  number  of  cases,  to  relieve  the  insensibiiit}-;  con- 
sciousness sometimes  returns  as  the  blood  flows.  But  the  indis- 
criminate use  of  this  powerful  remedy  is  the  surest  way  to  bring 
it  into  ultimate  disrepute.  A  distinction  should  be  drawn 
according  as  the  renal  disorder  is  acute  or  chronic  and  according 
to  the  strength  and  general  condition  of  the  patient.  It  must 
be  borne  in  mind  that  an  impoverished  and  watery  state  of  the 
blood  is  an  effective  factor  in  the  generation  of  ursemic  pheno- 
mena, and  that  a  bloodletting,  though  it  may  relieve  a  present 
attack,  increases  the  predisposition  to  future  attacks.  In  the 
ursemic  coma  of  acute  Bright's  disease,  and  in  certain  classes  of 
puerperal  eclampsia,  the  blood  is  as  yet  not  materially  impover- 
ished, and  the  type  of  renal  mischief  is  one  that  gives  full  hope 
of  eventual  recovery,  while  the  attack  itself  is  of  extreme 
danger.  In  these,  venesection — free,  and  even  repeated — is 
decidedly  and  urgently  demanded.  But  the  matter  stands  other- 
wise when  the  renal  mischief  is  chronic  and  incurable.  The 
attacks  themselves  are  not  so  imminently  dangerous  as  when 
occurring  in  the  acute  form  of  the  disease,  patients  frequently 
survive  repeated  ursemic  paroxysms  without  the  aid  of  venesec- 
tion ;  the  blood  is  commonly  thin  and  poor;  and,  lastly,  there 
is  not  any  prospect  of  ultimate  recovery.  Under  these  circum- 
stances loss  of  blood  is  more  likelj^  to  shorten  than  to  lengthen 
life.  Further,  as  Christison  remarks  (speaking  of  advanced 
renal  mischief),  when  the  torpor  becomes  considerable  the  .re- 
moval of  blood  seems  of  little  or  no  use.  In  some  of  the  cases 
reported  by  Bright,  death  occurred  from  coma  on  the  very  da}^ 
of  free  and  repeated  venesection.  I  can  only  conceive  of  two 
contingencies  in  which  withdrawal  of  blood,  in  quantity,  is 
justifiable  in  chronic  renal  disease;  one  is,  when  coma  comes  on 
rapidly  in  a  person  whose  constitution  is  not,  as  yet,  seriously 
deteriorated,   and   whose    prospects    of    life    (abstracting    the- 


448  CHRONIC  bright's  disease. 

uraemia)  may  extend  to  many  months  or  some  years;  the  other 
is,  when  there  is  a  necessity  for  temporary  restoration  of  the 
faculties  paramount  to  the  general  chance  of  prolonging  life. 

When  the  comatose  symptoms  come  on  gradually,  the  meas- 
ures before  enumerated  should  in  every  case  take  precedence  of 
bloodletting. 

Of  late  years,  a  therapeutic  agent,  most  valuable  in  cases  of 
ursemia,  has  been  introduced,  in  the  form  of  pilocarpin,  the 
alkaloid  of  jaborandi.  When  a  dose  of  the  hydrochlorate  of 
pilocarpin  (^  to  ^  grain)  is  injected  under  the  skin,  profuse 
sweating  follows  in  a  very  short  time,  much  to  the  relief  of  the 
urfemic  symptoms.  The  drug  is  also  of  use  in  dropsical  states. 
It  is  prone,  however,  to  cause  symptoms  of  collapse,  which'must 
he  guarded  against  by  the  use  of  stimulants. 


CHAPTEK  Y. 

SUPPURATION  IN  THE  KIDNEY— RENAL  EMBOLISM. 

Purulent  formations  in  the  substance  of  the  kidney  arise 
under  three  conditions,  namely:  (1)  phlegmonoid  inflamma- 
tions ending  in  circumscribed  abscess;  (2)  multiple  abscesses 
from  purulent  infection ;  and  (3)  occasionally  from  embolism 
apart  from  pyremia.^ 

It  is  necessary  to  distinguish  between  abscess  situated  in  the 
substance  of  the  kidney,  and  purulent  distention  of  the  pelvis  and 
infundibula,  with  ultimate  sacculation  of  the  organ  (pyonephro- 
sis). These  two  conditions  were  confounded  under  the  common 
name  of  "  abscess  of  the  kidney,"  until  Rayer  pointed  out  the 
distinction  between  them. 

1.  Phlegmonoid  Abscess  is  nearly  always  confined  to  one  kid- 
ney. It  may  be  due  to  external  violence  (blows  or  falls  on  the 
loins),  or  to  inflammation  and  suppuration  round  a  calculus  or 
calculi  lodged  in  the  substance  of  the  gland,  or  it  may  arise  as 
a  sequence  to  suppuration  of  the  lower  urinary  passages.  In 
the  last-mentioned  cases  the  abscess  may  be  due  to  extension  of 
the  inflammation  by  continuity  of  tissue  along  the  straight  ducts 
of  the  pyramids ;  sometimes,  however,  the  primary  inflamma- 
tion is  confined  to  the  bladder  or  urethra  and  no  direct  con- 
nection between  the  two  foci  of  suppuration  is  evident.  Such 
cases  are  difficult  to  explain.      Most  probably  the  view  pro- 

1  Dr.  Johnson  describes  another  form  of  "suppurative  nephritis,"  in  which  pus 
is  produced  in  the  uriniferous  tubes  by  transformation  of  the  renal  epithelium. 
This  condition  he  found  associated  with  the  occurrence  of  "  purulent  casts  "  in 
the  urine.  I  have  frequently  noticed  casts  of  this  character,  but  am  disposed  to 
explain  their  appearance  diffeientlj^.  It  is  not  very  rare,  in  Bright's  disease,  to 
find,  in  the  urine,  cells  attached  to  fibrinous  casts  with  double  or  triple  nuclei. 
But  this  is  no  more  evidence  of  pus  than  the  occurrence  of  the  pale  corpuscles  in 
the  blood  (which  are,  anatomically,  indistinguishable  from  pus  corpuscles)  is  evi- 
dence of  pus  in  the  blood.  When  the  renal  cells  proliferate  rapidlj',  they  assume 
very  much  the  appearance  of  pus  corpuscles,  and  display  cleft  nuclei. 

The  cases  adduced  by  Dr.  Johnson  are  quite  inconclusive  ;  the  first  (Case -28) 
was  an  example  of  Bright's  disease  complicated  with  boils ;  pyiemia  followed  and 
metastatic  abscesses  were  found  in  the  kidneys  and  lungs  ;  the  second  case  (N"o.  29) 
seems  to  have  been  an  example  of  the  mottled  white  kidney  acutely  developed — 
complicated  with  cutaneous  erysipelas,  but  otherwise  not  unusual  in  its  course.  In 
the  third  case  dropsy  and  albuminuria  of  sudden  onset  had  come  on  in  an  intem- 
perate and  gouty  man.  Dr.  Johnson  found  purulent  casts  in  the  urine,  but  after 
a  while  they  disappeared,  and  the  patient  survived  nearly  a  year.  To  apply  the 
term  suppurative  nephritis  to  cases  like  the  last  two  is  likely  to  mislead,  for' they 
diflfer  nowise  clinically  from  typical  Bright's  disease. 

29 


450  EENAL    EMBOLISM. 

pounded  by  Klebs/  that  micrococci  are  the  agents  of  propa- 
gation, is  correct.  In  not  a  few  cases,  the  suppuration  in  the 
kidney  is  merely  a  local  manifestation  of  a  general  pysemic 
condition  'starting  in  the  lower  urinary  passages.  An  abscess 
formed  in  any  of  these  ways  may  involve  the  whole  kidney  in 
destruction  and  convert  it  into  a  bag  of  pus. 

An  abscess  of  the  kidney  generally  opens  into  the  pelvis  of 
the  organ,  and  its  contents  are  discharged  by  the  ureter.  This 
is  by  far  the  most  favorable  issue.  Sometimes  the  pus  works 
its  way  out  in  other  directions ;  it  may  penetrate  the  tunica 
propria  posteriorly,  and  be  evacuated  in  the  loins;  and  recov- 
eries have  taken  place  even  after  this  event,  though  generally 
such  cases  prove  ultimately  fatal.  A  renal  abscess,  more  rarely, 
bursts  into  the  colon  or  duodenum,  and  is  discharged  by  stool; 
or  it  penetrates  into  the  peritoneal  sac,  causing  rapid  death  ;  in 
still  rarer  cases,  it  has  been  known  to  push  into  the  cavity  of 
the  thorax  and  be  evacuated  by  coughing. 

The  symptoms  of  circumscribed  abscess  of  the  kidney  are 
pain  in  the  afiected  organ,  fever,  hsematuria,  successive  (often 
regular)  rigors;  and,  if  the  collection  be  sutficiently  large,  a 
fulness  or  fluctuating  tumor  is  perceived  in  the  renal  region. 
When  the  abscess  bursts  into  the  infundibula  there  is  sudden 
and  copious  discharge  of  pus  with  the  urine — or,  if  it  burst  into 
the  intestines,  with  the  stools — followed  by  simultaneous  sub- 
sidence of  the  tumor.  In  the  absence  of  fulness  in  the  renal 
region,  or  of  signs  of  pointing  in  the  loins,  the  diagnosis  is 
necessarily  uncertain.  Perinephritic  abscess  is  sometimes  ac- 
companied with  hsematuria,  and  other  signs  greatly  resembling 
those  of  abscess  in  the  renal  substance.^  Albuminuria  is  by  no 
means  a  necessary  symptom  of  suppuration  in  the  kidney.  It 
may  be  wholly  absent,  or  the  urine  may  contain  a  small  quantity 
of  albumen.  "When  abscesses  of  the  kidney  form  slowly  in  the 
course  of  suppurating  disease  of  the  lower  urinary  passages, 
they  are  usually  unassociated  with  any  special  symptoms,  and 
their  existence  may  not  be  suspected  until  the  autopsy. 

Sometimes  the  contents  of  a  renal  abscess,  instead  of  being 
evacuated,  are  gradually  inspissated;  the  liquid  parts  of  the  pus 
are  absorbed,  and  the  residue  is  dried  up  into  a  puttj^-like  mass 
containing  shrunken  pus  corpuscles  mixed  with  considerable 
quantities  of  phosphate   and    carbonate  of  lime.      When   an 

^  Handbuch  d.  path.  Anatomie,  p.  654.  The  septic  material  may  reach  the 
kidney  through  the  renal  tvibules,  or,  as  pointed  out  by  Mr.  Marcus  Beck,  it  may 
pass  into  the  lymphatics  surroundinai;  the  pelvis  and  straight  tubes  of  the  kidnej^, 
by  means  of  breaches  in  the  epithelial  surface,  and  so  become  disseminated  through 
the  whole  organ.  See,  also,  a  paper  by  Dr.  Stevens,  Glasg.  Med.  Journ.,Sept. 
1884. 

^  See  a  case  by  Todd.     Clin.  Lects.  on  Ur.  Dis.,  p.  39. 


RENAL    EMBOLISM.  451 

abscess  dries  up  in  this  manner  it  may  lie  permanently  latent, 
and  £^ive  no  further  trouble.  The  destruction  of  one  kidney 
in  this  way  is  corn[)en8ated  by  enlargement  of  the  opposite 
healthy  organ,  which  is  thus  enabled  alone  to  carry  on  the  renal 
function. 

Treatment. — When  external  violence  has  been  so  inflicted 
that  there  is  reason  to  apprehend  suppurative  inflammation,  the 
loins  should  be  freely  cupped  or  leeched;  absolute  rest  and  low 
diet  should  be  enjoyed  for  several  days,  and  the  bowels  kept  open 
by  emollient  clysters.  The  same  treatment  should  be  followed 
in  principle,  but  modified  to  suit  the  accompanying  circum- 
stances, if  abscess  is  threatened  from  renal  calculi. 

When  signs  of  pointing  in  the  loins  are  recognized,  they 
should  be  encouraged  by  warm  poultices ;  and  as  the  pus  ap- 
proaches the  surface  it  should  be  evacuated,  in  order  to  forestal 
the  danger  of  evacuation  by  the  more  dangerous  channels  of 
the  peritoneum  or  thorax.  Too  often  the  original  cause  of  the 
suppuration  (impacted  calculi  or  disease  of  the  lower  urinary 
passages)  is  irremovable,  and  the  evacuation  of  one  abscess  is 
liable  to  be  followed  by  the  formation  of  others,  which  at  length 
exhaust  the  patient.' 

2.  Multiple  or  Metastatic  Abscesses. — Secondary  abscesses 
are  sometimes  found  in  the  kidneys,  as  well  as  other  parts  of 
the  body,  after  death  from  pyaemia.  The  kidneys  are,  however, 
less  frequently  the  seat  of  such  abscesses  than  the  lungs  and 
liver.  In  2161  autopsies  performed  at  St.  George's  Hospital, 
Dr.  Chambers  found  pysemic  abscesses  in  the  kidney  12  times ; 
in  the  lungs,  106  times,  and  22  times  in  the  liver.  The  implica- 
tion of  the  kidneys  has  been  found  in  pyaemia  from  almost  every 
cause — after  amputations,  lithotomy,  lithotrity,  and  other  surgical 
operations,  gangrenous  aflJections,  carbuncle,  glanders,  variola, 
chronic  suppurations,  especially  of  the  lower  urinary  passages. 
In  foul"  instances  Dr.  Chambers  found  the  kidneys  free  from 
abscesses  when  the  pysemia  had  arisen  from  disease  of  the  uri- 
nary passages  themselves. 

The  primar}^  disorder  (pyfemia)   is    of   such    overwhelming 

1  Illustrative  cases  of  abscess  of  the  kidney  may  be  found  (in  addition  to  those 
indicated  at  the  head  of  tlie  chapter)  in  the  following  sources:  Lancet,  1847,  i. 
p.  335;  1853,  i.  p.  32;  1863,  ii.  p.  69;  1873,  ii.  p.  772.  Med.  Times  and  Gaz., 
1854,  i.  p.  23;  and  ii.  pp.  241,  343;  1874,  ii.  p.  632.  Med.  Gazette,  vol.  xis..  p, 
888;  XXIV.  p.  563;  xxvii.  p.  141;  xlv.  p.  252.  Path.  Soc.  Trans.,  1849-1850,  p. 
234;  vol.  V.  pp.  178,  179;  xiii.  p.  131.  Gaz.  Hebd.,  1863,  p.  40.  Dublin  Hosp. 
Gaz.,  1854,  p.  147;  and  vol.  i.  p.  121.  Med.-Chir.  Eev.  (1824-1834),  new  series, 
xii.  p.  81 ;  xix  pp.  159,  234.  Med.  Commentaries,  vii.  p.  41.  Med.  Facts  and 
Obs.,  vi.  No.  3.  Encycl.  d.  Sc.  Med.,  v.  54,  p.  19.  Wilson,  Lects.  on  Dis.  of  Ur. 
Organs,  Lond.  1821,  pp.  281,  283.  Bennet,  Clin.  Lects.,  2d  ed.,  p.  731.  Ulrich, 
cited  by  Kosenstein,  loc.  cit.,  p.  287.  Southey,  Clin.  Soc.  Trans.,  1869,  p.  58. 
Burritt,  Med.  and  Surg.  Eep.  of  New  Orleans,  1868,  p.  520.  Hough,  Amer. 
Journ.,  1870,  p.  280,  also  Arch.  Gen.,  1869,  p.  348. 


452  RENAL    EMBOLISM. 

gravity,  that  the  renal  lesion  becomes  by  comparison  unimpor- 
tant. 1^0  symptoms  are  known  whereby  the  existence  of  multi- 
ple abscesses  in  the  kidneys  can  be  predicated  with  certainty 
during  life.'  A  strong  probability  that  such  abscesses  exist  will 
arise  if,  with  evident  pysemia,  the  renal  regions  are  painful  on 
pressure  and  a  considerable  quantity  of  albumen  be  discharged 
with  the  urine. 

Sometimes  the  secondary  abscesses  in  pyaemia  are  almost 
confined  to  the  kidneys,  as  in  the  following  example : 

Ou  January  9,  1865,  I  examined  the  body  of  a  man,  aet.  about  45, 
who  had  died  in  the  Salford  Workhouse,  a  day  or  two  after  his  admis- 
sion, of  some  obscure  disease.  The  bladder  was  found  thickened  and 
contracted ;  the  mucous  membrane  softened,  red  and  congested,  but  not 
ulcerated.  The  ureters  were  dilated  to  the  thickness  of  a  large  quill. 
The  kidneys  were  enlarged  to  about  twice  their  natural  size,  and  riddled 
with  hundreds  of  minute  abscesses,  the  largest  of  which  were  about  the 
size  of  a  hoarse-bean  and  the  smallest  like  pins'  heads.  They  were  dis- 
tributed through  the  substance  of  the  organs  and  on  their  surfaces, 
mostly  aggregated  into  groups  varying  from  the  size  of  a  sixpence  to 
that  of  a  florin.  Each  abscess  was  surrounded  Avith  a  red  inflamed 
areola.  Some  of  those  on  the  surface  appeared  thinned  away  almost  to 
bursting,  and  in  places,  resembled  a  patch  of  herpetic  eruption.  Not 
one  of  these  abscesses  had  opened  into  the  infundibula ;  and  if  pus  had 
made  its  way  into  the  ureter  from  the  kidney,  it  must  have  drained  along 
the  uriniferous  ducts.  On  section  it  was  seen  that  the  little  abscesses 
displayed  a  general  tendency  to  range  themselves  end  to  end,  in  lines 
following  the  direction  of  the  ducts  of  the  pyramids. 

There  were  about  8  ounces  of  urine  in  the  bladder ;  it  deposited,  on 
standing,  an  abundant  sediment  of  pus ;  it  also  contained  a  good  deal  of 
albumen — more  than  the  pus  accounted  for.  Careful  examination  failed 
to  discover  casts  of  tubes  of  any  sort. 

Both  lungs  contained  a  few  secondary  abscesses ;  there  was  abundant 
recent  pleurisy  on  both  sides.  The  right  heart  was  somewhat  dilated  ; 
otherwise  the  organ  was  healthy.     The  liver  was  healthy. 

The  pysemia  in  this  case  appeared  to  have  arisen  from  chronic  cystitis. 

The  exciting  cause  of  the  abscesses  is  probabl}^  in  every 
instance  the  presence  of  micrococci.  Often  the  capillaries  in 
the  neighborhood  are  found  crowded  with  micrococci,  and  no 
embolism  can  be  discovered.  In  some  cases,  however,  a  small 
vessel  is  blocked  by  a  portion  of  clot  discharged  from  an  in- 
flamed vein,  and,  in  the  manner  to  be  presently  described,  an 
infarct  is  produced  which  rapidly  goes  on  to  suppuration ;  the 
determining  cause  of  pus-formation,  even  in  this  case,  is  most 
likely  the  irritation  produced  by  the  presence  of  microorgan- 
isms. 

3.  Renal  Embolism. — It  was  well  known  to  Rayer  that  rheu- 
matic endocarditis  was  sometimes  attended  with  the  formation 


RENAL    EMBOLISM.  453 

of  numerous  deposits  of  a  yellow  color  in  the  kidneys,  which 
he  considered  to  have  the  nature  of  plastic  lymph.  He  de- 
scribed and  ligured  such  cases  under  the  designation  of 
"  nephrite  rhumatismale.'"  But  it  was  not  until  the  doctrine 
of  embolism  was  worked  out  by  Kirkes,  Virchow,  and  others, 
that  the  real  nature  of  these  lesions  was  understood. 

The  loose  fibrinous  vegetations  which  beset  the  aortic  and 
mitral  valves  in  endocarditis  are  apt  to  be  detached,  and  swept 
away  with  the  current  of  blood  into  the  arterial  system,  and 
to  be  finally  impacted  in  some  small  artery  in  the  brain,  kid- 
neys, or  other  part.  But  it  is  not  solely  in  endocarditis  that 
such  masses  are  dislodged  and  carried  away.  The  same  may 
happen  in  atheromatous  erosions  of  the  valves  and  aorta;  or  a 
portion  of  the  fibrinous  lining  of  an  aneurism  may  be  detached 
and  whirled  away  to  the  kidneys  and  other  places.^ 

The  efifect  of  the  lodgement  of  plugs  or  emboli  from  any  of 
these  sources  in  the  arteries  of  the  kidneys  varies  wnth  their 
magnitude.  Small  emboli  either  do  not  produce  any  appreciable 
symptoms,  or  they  merely  occasion  a  dull  uneasiness  in  the 
renal  region;  and  their  existence  is  only  ascertained  by  in- 
spection after  death.  But  if  one  of  the  larger  arteries  is 
plugged  up,  not  only  does  the  occurrence  produce  symptoms 
referrible  to  the  kidneys  (sudden  acute  pain  in  the  loin  shooting 
down  the  ureter),  but  it  may,  under  favorable  circumstances, 
even  be  diagnosticated  during  life.^ 

In  three  cases  of  embolism  described  by  Kirkes  (in  which 
death  ensued  from  softening  of  the  brain,  consequent  on  ob- 
struction of  one  of  the  main  cerebral  arteries,  by  a  fibrinous 
plug  derived  from  warty  vegetations  on  the  valves  of  the  left 
heart),  the  kidneys  were  the  seat  of  numerous  masses  of  yellow 
deposit  surrounded  by  red  areolae.  An  injection  throw'n  into 
the  renal  artery  did  not  penetrate  in  the  least  degree  into  these 
yellow  patches.  The  further  researches  of  Yirchow  and  Beck- 
mann  have  added  some  particulars  to  the  description  of  Kirkes. 
The  yellow  spots  are  situated  almost  exclusively  in  the  cortical 
substance ;  they  are  frequently  wedge-shaped,  with  their  bases 
bulging  underneath  the  tunica  propria,  and  their  apices  pointing 
toward  the  infundibula.  They  vary  in  size  from  a  hemp-seed 
to  a  hazel-nut.  At  first  they  look  like  red  hemorrhagic 
patches;  in  the  centre  of  each  there  soon  appears  a  yellow  spot.* 

1  Kayer,  loc.  cit.,  t.  ii.  p.  73.     Atlas,  pi.  v. 

^  See  the  history  of  a  case  of  aortic  aneurism,  by  Murchison  and  Moore,  in  vol. 
xlvii.  of  the  Med.-Chir.  Trans.,  p.  129. 

■''  Such  a  case  is  related  by  Traube,  loc.  cit.,  p.  77. 

*  From  more  recent  researches,  it  appears  doubtful  whether  the  infarct  of  the 
kidney  ever  assumes  the  hemorrhagic  form,  except  when  occui-ring  together  with 
venous  stagnation.  Certainly,  in  the  post-mortem  room,  it  is  nearly  always  met 
with  in  the  form  of  a  yellow  mass.     The  reason  of  this  is  not  clear. 


454  RENAL    EMBOLISM. 

This  enlarges,  and  either  softens  in  the  centre  (breaking  down 
into  a  fatty  debris,  more  rarely  into  genuine  pus)  or  finally  con- 
tracts into  a  cicatricial  remnant,  with  destruction  of  the  adjacent 
secreting  tissue.  It  is  necessarily  a  matter  of  extreme  difficulty 
to  demonstrate  the  existence  of  obstructions  or  plugs  in  the 
minute  vessels  at  or  near  one  of  these  yellow  spots,  and  some 
doubt  yet  hangs  over  the  demonstration.  When  one  of  the 
main  branches  is  obstructed,  the  embolus  is  more  easily  dis- 
covered, and  the  appearances  are  somewhat  different.  The  first 
efiect  of  cutting  off  the  arterial  supply  of  a  considerable  section 
of  the  kidney  is  to  produce  intense  hypersemia  of  the  surround- 
ing parts,  which  results  in  rupture  of  the  capillaries  and  effusion 
of  blood  into  the  surrounding  tissue.  In  this  way  a  wedge- 
shaped  apoplectic  area  is  formed,  embracing  the  whole  thickness 
of  the  organ.  Cohnheim  found  that  in  similarly  produced 
lesions  in  the  frog's  tongue,  the  current  in  the  veins  was 
reversed,  and  assisted  in  the  congestion  of  the  infarct. 

As  a  rule,  the  effects  of  embolism  in  the  kidney  are  of  very 
slight  clinical  importance;  they  pass  by,  in  the  immense  ma- 
jority of  cases,  without  recognition;  their  occurrence  is  always 
secondary  to  some  much  more  grave  primary  disorder,  which 
altogether  dominates  the  prognosis  and  treatment.  Sometimes 
the  larger  ones  go  on  to  suppuration,  and,  still  more  rarely,  to 
gangrene. 


CHAPTER    yi. 

PYELITIS  AND  PYONEPHROSIS. 

Morbid  Anatomy. — Inflammation  of  the  pelvis  and  calices 
of  the  kidneys,  or  pyelitis,  may  be  acute  or  chronic;  it  may 
involve  the  two  sides,  or  be  confined  to  one. 

In  acute  pyelitis  the  mucous  membrane  is  injected  ;  some- 
times minute  ecchymoses  dot  its  surface,  and  blood  may  be 
effused  on  it ;  the  epithelium  is  more  or  less  freely  shed,  and  at  a 
later  period  pus  is  formed.  In  rare  cases,  the  surface  is  lined 
with  false  membranes  (diphtheritic  pyelitis)  which  are  liable  to 
be  detached,  and  to  block  up  the  ureter. 

In  chronic  pyelitis  the  mucous  membrane  has  a  dead-white 
color,  sometimes  gray,  or  slate ;  either  it  is  not  at  all  injected  or 
it  is  traversed  by  dilated  veins.  The  membrane  is  also  thickened, 
and  the  pelvis  and  infundibula  are  dilated.  This  dilation,  as  it 
proceeds,  encroaches  more  and  more  on  the  substance  of  the 
gland  :  first  the  papillae  are  flattened  or  obliterated ;  next  the 
pyramids,  and  finally  the  cortex  are  gradually  annihilated,  and 
the  organ  is  wholly  excavated  (or  sacculated)  and  transformed 
into  a  multilocular  pouch  filled  with  pus.  Rayer  describes  and 
figures  examples  in  which  the  pelvic  membrane  was  studded 
with  minute  vesicles  resembling  sudamina- 

When  the  disease  is  due  to  the  lodgement  of  calculi,  ulcera- 
tions may  exist  on  the  mucous  membrane,  and  sometimes  these 
have  been  known  to  lead  to  perforation,  with  effusion  of  pus 
and  urine  into  the  surrounding  cellular  tissues,  or  into  the 
intestines  or  peritoneum.  The  accidents  usually  occur  after 
sacculation  and  dilatation  of  the  kidney  have  taken  place,  but 
sometimes  when  the  organ  does  not  transcend  its  ordinary 
dimensions. 

When  the  pus  and  urine  lodged  in  an  excavated  kidney  fail 
to  find  a  free  exit  through  the  ureter,  from  blocking  up  of  its 
channel  by  a  calculus,  a  clot  of  blood,  thickened  pus,  tuber- 
culous or  cancerous  debris,  etc.,  these  fluids  accumulate  behind 
the  obstacle,  and  distend  the  organ  into  an  abscess-like  cavity 
(pyonephrosis),  which  sometimes  forms  a  palpable  tumor  in  the 
flank.  The  matter  so  incarcerated  may  open  a  way  for  itself  in 
any  direction — backward  through  the  loin ;  downward  along 
the  psoas  muscle  into  the  iliac  fossa,  or  under  Poupart's  liga- 
ment; upwards  into  the  bronchial  tubes,  though  this  is  rare; 


456  PYELITIS. 

more  frequently  it  penetrates  into  the  duodenum  or  colon ;  or 
lastly,  into  the  peritoneum. 

In  the  cavity  of  the  inflamed  pelvis  there  are  often  found,  in 
addition  to  pus  and  urine,  blood,  urinary  calculi  of  various 
shapes  and  number,  calcareous  crusts,  hydatids,  tubercle,  cancer, 
or  whatever  other  foreign  or  adventitious  matter  may  have  been 
the  cause  of  the  inflammation. 

If  the  urine  remain  acid,  uric  acid  and  the  urates  may  be 
precipitated  in  the  interior  of  the  pelvis ;  but  if  it  become 
ammoniacal,  as  it  commonly  does  in  advanced  cases,  the  mixed 
phosphates  are  thrown  down.  These  are  sometimes  produced 
in  great  quantity,  and  mingling  with  the  purulent  contents  of 
the  sac,  thicken  the  whole  into  a  semi-fluid  mortar-like  sub- 
stance. In  other  cases,  the  phosphatic  matter  forms  incrusta- 
tions, which  adhere  in  places  to  the  walls  of  the  cavity,  or  lie 
loose  as  friable  concretions.  Sometimes,  again,  the  excavated 
organ,  instead  of  forming  a  tumor  (or  as  a  subsequent  stage  to 
such  tumor),  slowly  contracts,  until  at  length  it  is  reduced  to  a 
shrivelled  pouch  weighing  only  a  few-  drachms. 

In  other  instances,  the  pus  is  gradually  inspissated  and  im- 
pregnated with  mineral  matter  (carbonates  and  phosphates  of 
lime  and  magnesia  (until  it  is  converted  into  a  putty  or  chalk- 
like material,  which  fills  up  the  compartments  of  the  sacculated 
kidney.  Sometimes  the  fibrous  septa  which  separate  the  com- 
partments are  extensively  calcified.  In  an  example  of  this 
kind  (exhibited  by  Dr.  John  Medd  to  the  Manchester  Medical 
Society)  which  was  handed  to  me  for  examination,  a  saw  was 
required  to  cut  the  kidney  across,  and  a  piece  of  one  of  the 
bony  septa  which  was  ground  down  displayed,  under  the 
microscope,  the  characters  of  true  bone,  though  in  a  rudimen- 
tary state.  A  fine  specimen  of  similar  transformation  is  pre- 
served in  the  museum  of  the  Owens  College,  of  which  Fig.  56  is 
a  representation. 

It  rarely  happens,  in  cases  of  chronic  pyelitis,  that  the  other 
parts  of  the  urinary  apparatus  are  free  from  disease.  The  most 
common  combination  is  chronic  cystitis  with  dilated,  thickened, 
suppurating  ureters.  The  substance  of  the  kidney,  or  what 
remains  of  it,  is  likewise  involved  at  length  in  a  degeneration 
of  the  nature  of  chronic  Bright's  disease  (pyelo-nephritis) ;  and 
if  both  kidneys  are  aftected,  the  usual  symptoms  of  that  dis- 
order present  themselves — general  anasarca  and  characteristic 
changes  in  the  urine. 

Etiology. — The  symptoms  of  pyelitis,  and  the  varied  acci- 
dents which  it  may  present  during  its  course,  whether  acute  or 
chronic,  have  so  direct  and  intimate  a  connection  with  the 
cause  of  the  inflammation,  that  practically  it  is  necessary  to 
couple  the  description  of  the  dififerent  species  of  pyelitis  with 


p:tiology. 


457 


an  etiological  condition.  This  h  so  far  true  that  the  designa- 
tion pyelitis  expresses  nothing  more  than  an  anatomical  fact. 
As  a  nosological  heading  it  includes  numljers  of  cases  which 
have  little  real  clinical  affinity.  In  a  certain  number  of  cases 
the  inflammation  of  the  pelvis  and  its  appendages  is  an  im- 
portant, perhaps  the  most  important,  feature  of  the  patient's 

Fig.  5f;. 


A  sacculated  kiduey  laid  open  ;  the  cavities  filled  with  a  solid  putty -like  matter. 


complaint;  but  in  the  majority  of  cases  pyelitis  is  a  subordinate 
and  often  insignificant  incident  in  the  history  of  some  graver 
disease.     Pyelitis  may  arise  under  very  varied  conditions,  viz. : 

(1)  From  overdoses  of  turpentine,  cautharides,  and  other 
stimulating  diuretics. 

(2)  Some  degree  of  pyelitis  usually  accompanies  both  acute 
and  chronic  Bright's  disease  and  diabetes. 

(3)  Certain  general  diseases  are  sometimes  complicated  with 
a  degree  of  pyelitis — typhus  and  other  eruptive  fevers,  pyemia, 
scurvy,  diphtheria,  cholera,  carbuncle,  etc. 


468  PYELITIS. 

(4)  From  mechanical  irritation  produced  by  the  presence  of 
a  foreign  body  in  the  pelvis  of  the  kidney  or  infundibula — 
urinary  gravel  and  calculi,  hydatids  and  other  parasites,  blood- 
clots,  cancerous  and  tubercular  deposits. 

(5)  From  stagnation  and  decomposition  of  the  urine  in  the 
pelvis  and  infundibula.  Simple  stagnation  of  the  urine  (with- 
out decomposition),  from  an  obstruction  in  the  ureter,  usually 
causes  only  dilatation  (hj^dronephrosis);  but  if  it  occur  suddenly, 
the  pressure  of  the  dammed-up  urine  may  excite  acute  pyelitis.^ 
Severer  inflammatory  changes  occur  if  the  stagnant  urine 
becomes  decomposed,  and  its  urea  converted  into  carbonate  of 
ammonia.  It  is  probable  that  the  intractable,  generally  fatal, 
pyelitis  which  sometimes  follows  pregnancy  arises  in  this  way. 

(6)  From  extension  upwards  of  inflammation  from  the 
bladder.  This  is  a  frequent  cause  of  the  worst  forms  of 
pj-elitis.  In  whatever  manner  cystitis  may  have  been  engen- 
dered—  whether  by  a  urinary  calculus,  enlarged  prostate, 
fungous  or  tubercular  disease  of  the  bladder,  or  stricture  of  the 
urethra — it  can  scarcely  persist  in  intensity  for  a  lengthened 
period  without  producing  some  or  all  of  the  following  conse- 
quences :  dilatation  and  suppuration  of  the  ureters,  pelvis,  and 
infundibula,  suppuration  extending  into  the  straight  tubes  and 
intertubular  spaces  with  formation  of  scattered  abscesses,  and 
ultimately  sacculation  of  the  kidneys  and  destruction  of  the 
renal  tissue.  The  term  "surgical  kidney"  has  been  infelici- 
tously  applied  to  this  series  of  changes  by  some  writers. 

(7)  From  the  extension  of  neighboring  inflammation,  such  as 
perinephritic  abscess,  or  inflammation  connected  with  caries  of 
the  vertebra,  as  in  a  case  reported  by  Dr.  Cullingworth.^ 

(8)  From  cold  and  unknown  causes.  It  is  very  rare  that 
pyelitis  is  not  secondary  to  some  antecedent  morbid  process  or 
mechanical  irritation  ;  but  now  and  then  cases  are  met  with,  in 
which  pyelitis  exists  without  any  definite  antecedent  to  account 
for  it,  as  in  the  following  example : 

In  March,  1857,  I  admitted  into  the  Manchester  Infirmary  a  man 
greatly  emaciated,  with  hectic  symptoms.  The  urine  contained  a  large 
quantity  of  pus ;  its  reaction  was  acid  ;  it  contained  no  casts  of  tubes, 
nor  more  albumen  than  the  pus  accounted  for.  The  patient  stated  that 
his  water  had  been  milky  for  more  than  a  year,  and  that  his  health  had 
been  gradually  failing  for  about  the  same  time.  He  had  never  passed 
any  gravel,  nor  had  he  ever  suffered  from  nephritic  colic.  As  far  as  he 
knew,  the  urine  had  never  been  bloody.  He  attributed  his  complaint 
to  the  nature  of  his  occupation,  which  was  to  manufacture  bichromate 

^  See  Si  case  reported  by  Brunner  in  the  Verhandl.  d.  phys.-med.     Gesellsch.  in 
"Wurzb.,  viii.  p.  146. 
2  Lancet,  1880,  i.  p.  14. 


SYMPTOMS.  459 

of  potash.  He  died  eleven  days  after  admission.  At  the  autopsy  the 
thoracic  organs  were  found  perfectly  healthy,  as  were  also  the  liver, 
spleen,  and  intestinal  tract.  When  the  bladder  was  opened,  some  in- 
jection of  the  mucous  membrane  was  found,  but  it  was  not  thickened, 
and  the  viscus  was  not  contracted.  Both  ureters  were  dilated  to  about 
double  their  usual  size,  and  filled  with  pus.  The  two  pelves  and  the 
infundibula  were  enlarged,  and  their  lining  membrane  opaque,  and 
bathed  in  pus.  The  kidneys  presented  very  slight  signs  of  disease;  the 
papillae  were  flattened  and  yellowish,  as  if  they  contained  pus  within 
their  ducts ;  the  remainder  of  the  renal  tissue  appeared  healthy.  No 
foreign  body  was  detected  in  either  pelvis,  and  the  path  of  the  urine 
was  free  throughout.  Death  could  only  be  attributed  to  the  long-con- 
tinued exhausting  purulent  discharge,  which  had  been  allowed  to  go  on 
without  an  attempt  to  check  it  until  within  eleven  days  of  his  death. 

Symptoms. — The  symptoms  of  pyelitis  are  compounded  of 
those  directly  due  to  the  inflamed  state  of  the  pelvis  and  calices, 
and  of  those  of  the  primary  lesion  which  is  the  exciting  cause 
of  the  inflammation.  Only  the  former  will  be  dealt  with  in 
this  connection ;  the  latter  will  be  described  under  their  appro- 
priate headings. 

An  aching  pain  and  sense  of  weakness  in  the  back  are  rarely 
altogether  absent  in  pyelitis.  This  pain  may  be  confined  to  one 
loin  or  afltect  both,  according  as  the  disease  is  single  or  double. 
Sometimes,  however,  single  pyelitis  is  accompanied  with  pain 
over  both  kidneys.    The  pain  is  increased  on  pressure. 

Symptoms  of  nephritic  colic  are  generally  noted  at  one  time 
or  other,  or  repeatedly,  when  the  disease  is  due  to  the  lodge- 
ment of  a  stone.  Similar  attacks  are  also  common  in  pyelitis^ 
from  hydatids ;  sometimes  also  in  tuberculous  and  cancerous 
pyelitis. 

The  most  important  direct  symptoms  of  pyelitis  are  found  in 
the  altered  characters  of  the  urine.  In  the  early  stage  the  urine 
contains  blood  (often  only  in  microscopic  quantity),  mucus,  and 
epithelial  cells  from  the  pelvis  and  infundibula.  The  appearance 
of  these  last  affords  the  most  certain  diagnostic  indications.  The 
pelvic  and  infundibular  cells  are  very  irregular,  spindle-shaped, 
tailed,  three-cornered,  elongated,  rudely  circular,  etc.  {see  Figs. 
23  and  53).  The  urine  is  usually  acid.  The  quantity  of  albu- 
men in  it  only  corresponds  to  the  admixed  blood  and  pus. 

In  the  more  advanced  stages,  the  characteristic  epithelium 
just  referred  to  is  usually  replaced  by  pus,  which  may  be  dis- 
charged in  large  quantities.  The  urine  is  still  commonly  acid ; 
but  as  the  sacculation  of  the  kidneys  proceeds,  the  mingled  pus 
and  urine  are  liable  to  decomposition,  and  the  urine  becomes 
ammoniacal. 

If  the  urinarj^  channels  remain  free,  the  discharge  of  pus  is 
constant  and  regular;  but  if,  as  frequently  happens,  the  ureter 


460  •        PYELITIS. 

is  blocked  up  by  a  calculus,  a  hydatid,  a  clot  of  blood,  a  mass 
of  viscid  pus,  or  other  debris,  the  discharge  of  pus  is  for  a  while 
arrested ;  and  if  the  disease  be  confined  to  one  side,  the  urine 
temporarily  recovers  its  transparency  and  healthy  characters. 
When  the  obstacle  gives  waj^  pus  suddenly  reappears  in  great 
quantity  in  the  urine.  If  the  distention  of  the  pelvis  have  pro- 
ceeded to  the  formation  of  a  tumor  in  the  flank,  the  intumescence 
is  necessarily  greatly  influenced  by  the  formation  and  removal 
of  such  an  obstacle.  When  the  discharge  of  pus  diminishes, 
the  fulness  in  the  flank  increases,  and  becomes  painful;  when 
the  course  of  the  pus  is  reestablished,  the  tumor  suddenly 
subsides,  and  the  urine  becomes  again  loaded  with  pus.  This 
train  of  events  throws  a  strong  light  on  the  nature  of  the  case. 
The  stoppage  in  the  ureter  may  persist  for  varying  periods — a 
few  days  or  a  few  months — or  it  may  prove  permanent.  When 
both  sides  are  affected  the  obstruction  of  one  ureter  diminishes, 
but  does  not  entirely  dissipate  the  pus  from  the  urine  ;  the  same 
is  also  the  case  when  the  impediment  is  partial. 

Micturition  is  always  more  frequent  than  natural  in  pyelitis ; 
and  during  the  nephritic  attacks  it  is  painful  and  incessant. 

Rigors  are  of  frequent  occurrence,  especially  when  there  is 
tumor;  they  sometimes  assume  a  quotidian  periodicity — recur- 
ring every  evening  with  tolerable  regularity.  Well-marked 
hectic  is  often  present  in  the  later  periods. 

The  bowels  are  frequently  disordered.  ITnmanageable 
diarrhoea  usually  prevails,  induced  doubtless  by  the  inflam- 
matory adhesions  which  take  place  between  the  dilated  kidney 
and  the  colon  which  passes  over  it.  In  other  cases  (when  there 
is  tumor)  the  bowels  are  obstinately  constipated,  and  require  the 
frequent  use  of  enemata.  This  is  occasioned  by  the  pressure  of 
the  tumor  on  the  colon ;  in  one  case,  related  by  Bright,  the 
descending  colon  was  so  contracted  from  the  pressure  of  a  pyone- 
phrotic  tumor,  that  it  was  reduced  to  the  condition  and  appear- 
ance of  a  thick  cord. 

The  occurrence  of  tumor  in  the  flank  is  generally  a  late  event 
in  the  course  of  pyelitis.  This  tumor  is  usually  the  seat  of 
fluctuation,  often  obscure;  and  is  commonly  painful,  and  tender 
on  pressure.  It  is  dull  on  percussion,  except  where  it  is  crossed 
by  the  colon.  When  the  tumor  is  on  the  right  side  it  is  sepa- 
rated from  the  liver  by  the  transverse  colon ;  when,  however, 
adhesions  form  between  the  sac  and  the  under  surface  of  the 
liver,  this  sign  may  be  wanting.  The  tumor  is  subject  to  im- 
portant variations  of  size,  as  already  explained,  according  to  the 
open  or  obstructed  state  of  the  outflow  from  it  into  the  bladder. 
In  some  cases  the  tumor  is  so  large  that  it  extends  across  the 
middle  line ;  more  commonly  it  amounts  only  to  a  fulness  in 
the  loin  or  in  the  space  between  the  crest  of  the  ilium  and  the 


ILLUSTRATIVE    CASES.  461 

false  ribs.  The  outline  of  the  abdomen  is  thus  rendered  lui- 
symmetrical. 

The  ultimate  issues  of  pyonephrosis  are  diverse;  scarcely  any 
two  cases  run  a  parallel  course.  The  various  directions  in 
which  the  sac  may  burst  have  already  been  noticed  (|).  453),  and 
the  symptoms  vary  correspondingly.  But  the  sac  may  not  burst 
at  all,  and  the  patient  dies  exhausted  by  the  wasting  discharge. 
This  is  indeed  by  far  the  most  common  termination.  Or  again, 
things  may  take  a  more  favorable  turn ;  the  discharge  gradually 
diminishes,  and,  tinally,  ceases  altogether:  the  sac  contracts  and 
dries  up,  and,  if  the  opposite  kidney  remain  sound,  perfect  restor- 
ation to  health  takes  place.  Or  the  restoration  may  take  place 
differently  :  the  purulent  collection,  instead  of  being  discharged, 
dries  up  into  a  putty -like  mass,  and  ceases  to  give  further  trouble. 

The  following  abstract  of  cases  will  serve  to  illustrate  the 
€Ourse  and  symptoms  of  some  of  the  chief  types  of  chronic 
pyelitis.  Other  illustrations  will  be  found  in  the  chapters  treat- 
ing of  parasites,  tubercle,  and  cancer  in  the  kidneys. 

Case  1.  Double  calculous  pyelitis  (Dance,  "Archives  Gen.,"  xxix. 
149). — A  young  woman,  set.  23,  was  admitted  into  the  Hotel  Dieu, 
January  12,  1824.  She  had  experienced,  two  years  and  a  half  before, 
a  tedious  illness,  which  commenced  with  hsematuria,  accompanied  by 
fixed  and  continued  pains  in  the  renal  region.  Subsequently,  the  urine 
became  turbid  and  purulent ;  it  was  passed  in  small  quantity  and  fre- 
quently. At  the  end  of  eighteen  months,  after  the  application  of  a 
large  number  of  leeches  to  the  loins,  the  health  improved.  The  renal 
pains  gave  place  to  an  habitual  sense  of  weight  in  the  loins  ;  the  urine, 
however,  continued  purulent.  Three  weeks  before,  the  menstrual  dis- 
charge was  suddenly  suppressed  from  cold  ;  and  when  the  patient  came 
under  observation  the  face  was  drawn,  the  eyes  sunken ;  there  were 
severe  abdominal  pains  increased  by  pressure ;  these  were  especially 
severe  in  the  lumbar  regiou.  The  urine  was  turbid,  scanty,  and  voided 
with  pain.  Leeches  wei^e  freely  applied.  But  obstinate  vomiting  came 
on,  and  the  patient  died  in  five  days. 

Autopsy. — The  kidneys  were  enlarged  to  about  a  third  above  their 
ordinary  size  ;  their  surfaces  were  nodulated,  and  unnaturally  hard,  but 
presenting  here  and  there  points  of  fluctuation.  On  cutting  open  the 
organs  they  were  found  extensively  sacculated  and  full  of  pus.  The 
left  kidney  contained  nine  calculi,  and  the  right  fifteen  ;  these  Avere 
lodged  in  the  dilated  calices.  The  proper  substance  of  the  kidney  was 
expanded  and  attenuated,  but  otherwise  healthy.  The  ureters  wer.e  dark 
colored,  marbled  on  the  surface,  and  their  lining  membrane  thickened. 

Case  2.  Tumor  formed  by  the  left  kidney  (pyonephrosis),  discharging 
pus  copiously  both  by  the  urethra  and  the  rectum,  depending  on  a  large 
renal  calcidus  (Bright,  loc.  cit.,  p.  227). — A  man,  ?et.  40,  first  seen  by 
Dr.  Bright,  April  30,  1836,  had,  for  the  last  twenty  years,  experienced 
occasional  pain  in  the  left  side,  Avhich  he  ascribed  to  a  blow  ;  he  had 
likewise,  at  times,  felt  pain  in  passing  urine,  which  was  then  turbid  with 


462  PYELITIS. 

deposit ;  but  about  three  months  only  before  Dr.  B.'s  visit,  had  a  tumor 
been  detected  or  suspected  in  the  left  lumbar  and  iliac  regions.  He 
was  found  considerably  emaciated.  The  urine  was  neutral,  with  a  very 
disagreeable  smell,  and  contained  a  large  quantity  of  pus  with  a  little 
blood.  The  whole  quantity  of  pus  passed  daily  was  from  four  to  six 
ounces. 

A  tumor  existed  on  the  left  side  of  the  abdomen  descending  far  below 
the  umbilicus,  hard  to  the  touch,  and  fixed  in  the  left  lumbar  and  iliac 
regions.     It  felt  smooth  and  even,  and  was  rather  tender  at  one  point. 

A  month  later  (June  1st)  the  tumor  appeared  to  occupy  nearly  the 
situation  of  an  enlarged  spleen,  but  Dr.  B.  thought  he  felt  the  colon 
passing  over  it.  The  urine  passed  in  twenty-four  hours  contained  only 
three  ounces  of  pus.     The  perspirations  were  profuse.     • 

June  6. — He  had  suffered  lately  a  good  deal  of  pain  in  the  left  side, 
and  was  evidently  feverish  ;  he  was  accordingly  directed  to  leave  off  the 
tonic  and  nourishing  medicines  and  food  he  had  been  taking. 

15th. — Two  days  after  the  last  visit  diarrhoea  came  on,  accompanied 
with  tenesmus.  The  tumor  was  found  now  greatly  diminished ;  and  on 
examining  the  stools  it  was  evident  that  a  large  quantity  of  pus  was 
passing  that  way.  The  discharge  of  pus  with  the  urine  was  undimin- 
ished, but  there  could  be  no  doubt  that  the  abscess  in  the  kidney  had 
ulcerated  into  the  descending  colon.  The  patient  lived  for  about  six 
weeks  after  this ;  hiccup  came  on  and  proved  very  obstinate ;  and  pus 
continued  to  be  discharged  both  from  the  urethra  and  the  rectum. 

Autopsy. — When  the  abdomen  was  opened,  the  left  kidney  was  seen 
occupying  the  space  from  the  diaphragm  to  the  brim  of  the  pelvis,  and 
along  its  whole  length  passed  the  descending  colon,  much  contracted. 
There  was  a  small  fistulous  opening,  not  larger  than  sufficient  to  admit 
a  goosequill,  from  the  sac  into  the  sigmoid  flexure  of  the  colon  as  it 
passed  over  the  lower  part  of  the  kidney  just  at  the  point  where  peculiar 
tenderness  had  been  early  observed,  and  here  the  intestine  looked  a  little 
di'awn  in.  The  pus  was  found  to  have  escaped  into  the  psoas  and  lum- 
bar muscles  very  extensively.  On  removing  the  left  kidney,  and  examin- 
ing it  more  accurately,  it  was  found  to  contain  a  large  coral-formed, 
lithic  acid  calculus,  extending  its  branches  into  all  the  cavities  of  a  sac- 
culated pelvis.  The  kidney  was  full  of  pus,  and  in  several  parts  cere- 
briform  matter  was  sprouting  into  the  cavities  with  most  luxuriant 
growth,  into  which  tufts  of  vessels  were  seen  entering. 

Cases  of  this  class  being  surrounded  with  more  or  less  obscurity 
as  to  the  exact  state  of  things  v^ithin  the  abdomen,  are  more  in- 
structive when  the  revelations  of  the  autopsy  are  at  hand  to 
illuminate  the  clinical  history;  but  the  nature  of  some  of  the 
cases  which  end  in  recovery  is  so  clearly  indicated  by  their 
symptoms,  that  they  may  be-  cited  with  advantage,  and  without 
any  doubt  as  to  their  real  nature. 

The  following  is  from  Dr.  Todd  {loc.  cit.,  Case  48)  : 

Case  3. — A  female,  set.  25,  unmarried.  She  had  been  passing  pus 
with  the  urine  at  least  a  twelvemonth  before  admission  into  hospital, 


ILLUSTRATIVE    CA8ES.  463 

and  in  considerable  and  constant  quantity.  For  the  last  five  years  she 
had  suffered  pain  in  the  loins,  referred  especially  to  the  region  of  the 
right  kidney.  This  pain  varied  in  intensity ;  it  was  generally  slight  and 
dull,  but  now  and  then  severe.  There  had  been  no  symptoms  of  an 
acute  attack,  nor  any  rigors  or  vomiting.  She  never,  to  her  knowledge, 
voided  blood  in  the  urine,  nor  ever  passed  any  gravel  or  calculus ;  nor 
did  she  ever  seem  to  have  suffered  from  severe  pain  in  the  direction  of 
the  ureter. 

Rather  more  than  a  twelvemonth  before  her  admission  into  hospital, 
she  was  suddenly  attacked  with  retention  of  urine,  which  lasted  twenty- 
four  hours  ;  and  immediately  after  its  cessation,  she  first  began  to  notice 
in  the  urine  a  sediment,  which  presented  a  purulent  character.  This 
attack  of  retention  of  urine  was  preceded  by  slight  rigors,  but  the  con- 
stitutional disorder  was  of  so  mild  a  character  as  not  to  cause  her  to  lie 
up  at  all. 

When  admitted  into  hospital,  pus  was  passed  daily  with  the  urine  to 
the  extent  of  two  to  four  ounces  ;  yet  there  was  but  very  slight  general 
ailment. 

On  examination,  a  very  large  tumor  was  found  situated  in  the  region 
of  the  left  kidney,  forming  a  considerable  projection  beneath  the  abdo- 
minal wall.  This  tumor,  which  was  three  times  the  ordinary  bulk  of 
the  kidney,  was  elastic  and  yielding  to  the  touch,  and  communicated  the 
sensation  of  a  soft  elastic  swelling  tilled  with  fluid.  There  was  dulness 
on  percussion  all  over  the  surface  of  the  tumor,  which  was  smooth, 
round,  and  free  from  any  notches  or  projections. 

The  tumor  was  not  tender ;  the  patient  could  bear  it  to  be  handled 
without  pain,  unless  hard  pressure  were  used,  when  she  complained  of  a 
dull  pain.  Her  most  urgent  symptom  was  an  occasional  cutting  pain, 
referred  to  the  neck  of  the  bladder,  sometimes  accompanied  with  slight 
difficulty  of  micturition.  She  stated  that  occasionally  she  had  a  sensa- 
tion of  fulness  in  the  left  side,  which  would  go  off  rapidly,  as  if  some- 
thing had  burst,  and  then  there  would  very  soon  follow^  an  increased 
flow  of  pus  in  the  urine.  Sometimes  as  much  as  eight  ounces  of  pus 
would  be  passed  in  the  twenty-four  hours.  Dr.  Todd  diagnosticated  a 
stricture  of  the  ureter,  probably  near  the  bladder,  causing  backward 
pressure  on  the  kidney,  with  dilatation  and  sacculation  of  the  organ. 

Eighteen  months  afterwards,  the  patient  presented  herself  again  to  Dr. 
Todd.  She  stated  that,  on  quitting  the  hospital,  she  went  to  Brighton  ; 
there  she  improved  in  health  very  gi-eatly,  and  the  purulent  discharge 
gradually  diminished.  On  a  careful  examination  of  the  side  there  was 
no  trace  of  tumor ;  only  a  few  pus  globules  could  be  detected  in  the  urine, 
and  it  was  doubtful  whether  these  were  not  derived  from  the  vagina 
the  bladder. 

Case  4.  Pyonephrosis  from  calculus,  in  the  ureter  without  purulent 
urine  (Howison,  "  Ed.  Med.  Jouru.,"  1822,  p.  557). — A  medical  prac- 
titioner, set.  25,  had  severe  and  protracted  nephritic  symptoms  on  the 
left  side  at  the  age  of  15.  He  recovered  from  this  attack,  but  during 
the  subsequent  years  he  suffered  repeated  paroxysms  of  pain  in  the  left 
kidney,  extending  to  the  umbilicus.     The  urine  was  at  times  scanty,  and 


464  PYELITIS. 

once  or  twice  slightly  tinged  with  blood,  but  it  never  was  observed  to  be 
milky,  or  to  contain  anything  like  pus. 

Between  the  paroxysms  his  health  was  good  ;  he  followed  the  practice 
of  his  profession,  and  underwent  a  good  deal  of  fatigue.  The  most  dis- 
tinguishing symptom  in  these  paroxysms  was  fixed  pain,  of  a  gnawing  de- 
scription, extending  from  the  spine  toward  the  umbilical  region,  increased 
by  pressure,  even  the  slightest,  during  the  severity  of  the  attack.  There 
was  habitual  constipation,  and  a  most  unusual  sensitiveness  to  cold. 

His  last  attack  but  one  occurred  in  February,  1821 ;  he  recovered 
from  this  in  about  six  weeks,  after  being  bled  to  130  ounces.  He  became 
lusty  and  florid  after  this  attack,  and  was  able  to  take  long  journeys 
in  his  gig ;  but  riding  caused  so  much  pain  that  he  was  obliged  to  give 
it  up. 

About  September  he  underwent  a  good  deal  of  fatigue ;  and  it  was 
supposed  that  he  suffered  a  good  deal  of  pain,  from  being  observed  re- 
peatedly to  bend  his  body  forward  for  relief,  although  he  would  not 
allow  it  when  questioned. 

One  Thursday  evening,  towards  the  end  of  September,  he  went  to  bed 
earlier  than  usual,  complaining  of  fatigue.  He  rose  next  morning  at 
seven  o'clock,  and  his  last  fatal  attack  commenced  at  eight.  The  symp- 
toms resembled  those  of  the  former  paroxysms ;  there  was  intense  pain 
in  the  left  renal  region,  and  a  hardness  was  perceived  when  the  hand 
was  applied  to  the  seat  of  pain,  with  a  peculiar  sense  of  crepitation. 
The  symptoms  became  rapidly  aggravated,  and,  notwithstanding  all  the 
means  employed,  including  the  abstraction  of  blood  to  the  extent  of  150 
ounces  (!),  he  died  on  the  fourth  day."^ 

Autopsy. — The  left  kidney  and  pelvis  were  found  converted  into  a 
reniform  sac,  a  foot  long,  and  nine  inches  broad.  The  surface  of  this 
sac  was  marked  out  into  three  lobes.  When  opened  it  was  found  full 
of  a  fluid  resembling  pus,  mixed  with  serum.  The  renal  substance  had 
wholly  disappeared,  except  a  few  small  portions,  leaving  nothing  but  a 
cavernous  cyst,  consisting  of  the  proper  external  membrane  of  the  kid- 
ney and  its  internal  membrane  much  thickened.  It  was  divided  into 
three  large  irregular  cells,  freely  communicating  with  the  dilated  pelvis, 
into  the  apex  of  which  the  ureter  (of  its  natural  size)  opened.  The 
septa  between  the  cells  were  hard  like  cartilage  with  thickened  edges. 

The  orifice  of  the  ureter  was  closely  blocked  up  by  a  small  calculus. 

Case  5.  Stone  in  the  bladder  for  16  years — removal  by  the  recto-vesical 
operation — death  Jive  years  after  from  pyelitis. — James  H.,  set.  21,  was 
admitted,  under  my  care,  into  the  Royal  Infirmary,  September,  1858, 
laboring  under  symptoms  of  stone  in  the  bladder.  On  sounding,  a 
large  concretion  was  forthwith  detected.  The  patient  stated  that  he 
had  been  subject  to  difficulty  and  pain  in  making  water  since  he  was 
five  years  of  age.  When  he  came  under  treatment  he  was  emaciated 
almost  to  a  skeleton,  and  unable  to  leave  his  bed.  Micturition  was 
excessively  frequent,  the  urine  ammoniacal,  and  loaded  with  viscid  pus. 
By  rest  in  bed  and  anodyne  treatment,  the  symptoms  diminished  greatly 

^  It  seems  highly  probable  from  the  narrative  that  death  was  directly  caused  by 
loss  of  blood  ;  the  patient  insisted  on  venesection  ;  he  tightened  the  ligature,  and 
bled  himself  on  the  night  of  his  death. 


ILLUSTRATIVE    GASES.  465 

in  severity;  and  on  the  17th  of  December  he  was  jurlged  by  my  col- 
league, Mr.  Southara,  who  now  took  charge  of  the  case,  to  be  fit  for 
operation.  The  stone  was  removed  by  the  recto-vesical  section.  It 
weighed  over  41  ounces,  and  contained  a  nucleus  of  oxalate  of  lime, 
overlaid  with  an  immense  mass  of  secondary  phosphates. 

The  patient  made  a  slow  recovery  from  the  operation.  By  the  end  of 
April,  1859,  the  fistulous  communication  between  the  bladder  and  rectum 
appeared  closed ;  and  the  patient  was  discharged  in  excellent  health, 
rapidly  gaining  weight. 

The  subsequent  history  of  the  case,  up  to  the  time  of  his  death,  extends 
over  a  period  of  five  years.  Soon  after  leaving  the  Infirmary,  the  recto- 
vesical fistula  reopened,  and  it  never  afterwards  could  be  completely 
closed.  The  general  health  continued  good,  and  no  practical  inc(m- 
venience  arose  from  the  fistula,  lintil  about  a  twelvemonth  before  his 
death.  The  purulent  discharge  with  the  urine  then  began  to  increase ; 
he  lost  flesh,  and  gradually  sank  in  the  early  part  of  1864. 

Autopsy. — The  bladder,  ureters,  and  kidneys  were  removed  entire. 
The  bladder  was  contracted  and  thickened  ;  the  ureters  were  dilated  to 
the  size  of  a  little  finger,  and  were  long  and  tortuous ;  both  kidneys 
were  extensively  sacculated,  but  not  enlarged,  and  filled  with  pus  ;  and 
the  secreting  tissue  w^as  reduced  to  a  thin  layer  of  cortical  substance 
scarcely  half  an  inch  thick. 

Case  6.  Pyelitis,  with  tumor — coming  07ifive  months  after  jjccriurition — 
improvement. — B.  F.,  set.  33,  a  married  woman,  who  had  had  nine  chil- 
dren, was  admitted  under  my  care  into  the  Royal  Infirmary,  on  Novem- 
ber 30,  1866.  She  was  suffering  from  a  tumor  in  the  right  flank  and 
purulent  urine. 

Her  last  child  was  born  14  months  ago,  and  five  months  afterwards 
she  was  suddenly  seized,  while  scouring  the  floor,  with  stabbing  pain  in 
the  right  side,  just  under  the  costal  cartilages.  This  continued  off  and 
on  for  some  time,  and  kept  her  to  bed  for  days  together  at  times.  Some- 
where about  the  same  time,  she  also  perceived  a  small  lump  in  the  right 
flank,  which  was  painful  on  pressure.  About  three  months  later  she 
noticed  a  white  discharge  in  the  urine,  and  this  has  continued  ever 
since.  She  has  never  had  rigors  nor  pain  in  micturition.  The  bowels 
have  been  irregular,  diarrhoea  alternating  with  constipation. 

State  on  Admission. — The  patient  was  considerably  emaciated,  with  a 
dirty  sallow  skin  and  complexion.  The  lungs,  heart,  and  liver  pre- 
sented no  signs  of  disease.  The  abdomen  was  flaccid  and  somewhat  promi- 
nent. In  the  right  loin  a  smooth,  elastic,  globular  tumor  was  felt  which 
was  not  distinctly  fluctuating.  The  tumor  was  about  as  large  as  a  child's 
head ;  it  occupied  the  entire  right  flank,  and  extended  inwards  almost 
to  the  umbilicus  and  downwards  into  the  right  hypochondrium.  It  was 
perfectly  immovable,  and  very  tender  on  manipulation.  The  flank  was 
dull  on  percussion,  but  the  front  of  the  tumor  was  traversed  by  the 
ascending  colon,  which  could  sometimes  be  distinctly  traced  over  its  sur- 
face either  by  palpation  or  percussion.  Between  the  tumor  and  the 
hepatic  limits  a  line  of  clear  percussion  could  be  traced  (see  Fig.  57). 

The  urine  was  acid,  specific  gravity  1020,  turbid,  with  a  thick  deposit 
of  pus  at  the  bottom  of  the  glass.  It  only  contained  albumen  to  a 
degree  corresponding  with  the  quantity  of  pus. 

30 


466 


PYELITIS. 


The  patient  remained  in  the  Infirmary  for  three  weeks.  About  three 
ounces  of  pus  were  discharged  daily  with  the  urine.  In  the  second 
week  of  her  stay,  a  febrile  exacerbation  took  place,  the  tumor  became 
more  painful,  and  the  temperature  rose  to  101°  in  the  morning — its 
usual  average  being  about  99°.  The  pyrexia  subsided  in  three  days, 
and  this  was  coincident  with  the  discharge  of  a  large  quantity  of  pus. 
One  day  she  voided  as  much  as  eight  ounces  of  pus  with  the  urine.  The 
tumor  was  considerably  reduced  in  size,  and  became  more  flaccid  after 

Fig.  57. 


Case  of  B.  F.     Diagram  showing  the  position  of  the  tumor. 

this,  and  the  appetite  and  strength  improved.  The  reaction  of  the 
urine  was  throughout  acid,  though  often  only  faintly  so.  She  was  dis- 
charged, at  her  own  request,  on  December  23d. 

Though  the  correctness  of  the  diagnosis  was  not,  in  this  case, 
verified  by  a  post-mortem  examination,  it  scarcely  admitted  of 
any  doubt.  The  acid  reaction  of  the  urine,  and  the  corre- 
spondence in  the  size  and  tension  of  the  tumor  with  the  removal 
of  pus  discharged  in  the  urine,  together  with  the  physical  signs, 
clearly  indicated  the  existence  of  a  pyelitic  tumor ;  and  it  is 
probable  that  the  origin  of  it  was  connected  with  old  pyelitis 
coming  on  during  the  patient's  last  pregnancy. 

Case  7.  Pyelitis  with  tumor,  after  parturition  (Bright's  "  Memoirs  on 
Abdominal  Tumors,  New  Syd.  Soc."  p.  212). — A  woman,  set.  30,  was 
admitted  into  Guy's  Hospital,  June  18, 1832.     She  had  a  large  abdomi- 


DIAGNOSIS.  467 

nal  tumor.  It  occui)ied  a  situation  which  extended  over  nearly  half 
the  abdomen,  not  very  different  from  that  of  a  greatly  enlarged  spleen, 
but  running  back  more  completely  into  the  lumbar  region,  and  there 
affording  a  tense,  somewhat  elastic  feel.  It  appeared  to  be  perfectly 
fixed ;  even  when  the  patient  was  turned  completely  on  the  right  side, 
it  did  not  shift  its  place.  It  felt  as  if  fixed  to  the  ribs  themselves,  under 
their  margins,  which  were  obviously  protruded  a  little  by  its  bulk.  To- 
wards the  lower  parts,  and  particularly  below  the  crest  of  the  ilium, 
and  descending  towards  the  pelvis,  the  enlargement  felt  much  softer  and 
less  tense.  Dr.  B.  was  at  once  convinced  that  the  tumor  depended  on  a 
diseased  kidney,  and  it  seemed  likely  that  the  softness  of  the  lower  part 
might  arise  from  a  portion  of  the  intestine,  which  probably  was  the  colon 
passing  over  the  kidney. 

Three  years  before,  the  patient  had  suffered  for  many  months  from 
frequent  micturition,  with  pain  and  forcing — the  urine  being  occasionally 
tinged  with  blood.  Eighteen  months  after,  she  was  put  to  bed  with  a 
living  child,  and  about  six  weeks  subsequently,  she  first  discovered  the 
tumor.  Since  that,  however  (nine  months  before  her  admission;,  she 
had  borne  another  living  child,  and  about  Christmas  she  began  to  pass 
considerable  quantities  of  what  she  considered  "  matter"  with  the  urine. 

On  admission  she  was  feeble,  and  looking  hectic,  with  frequent  calls 
to  pass  urine,  and  pain  in  doing  so.  The  urine,  which  was  acid,  con- 
tained pus.  Some  days  the  quantity  of  pus  was  very  small ;  but  on 
other  days  as  much  as  six  or  eight  ounces  of  pure  pus  were  collected  ; 
and  after  a  large  discharge,  the  tumor  was  often  decidedly  reduced  for 
a  day  or  two.  The  bowels  were  costive.  About  the  13th  of  July,  chest 
symptoms  set  in,  with  diarrhoea,  under  which  she  sank. 

Autopsy.- — The  tumor  proved  to  be  the  distended  left  kidney  reaching 
from  the  diaphragm  to  the  brim  of  the  pelvis.  The  descending  colon, 
contracted  like  a  thick  cord,  ran  longitudinally  on  the  surface  of  the 
tumor.  The  tumor  was  adherent  to  the  colon  and  the  lumbar  parietes. 
The  flattened  pancreas  lay  across  its  surface,  on  its  anterior  and  inner 
aspect.  The  ureter  was  thickened,  and  resembled  an  artery,  but  its 
canal  was  by  no  means  proportionably  large.  It  was  traced  to  the 
bladder,  where  its  orifice  formed  a  permanent  opening,  into  which  a 
goosequill  could  easily  have  been  inserted,  and  the  membrane  was  tuber- 
culated.  The  bladder  was  exceedingly  small ;  the  uterus  natural.  The 
tumor  contained  about  a  pint  and  a  half  of  healthy,  well-formed  pus, 
lodged  in  cells  communicating  with  the  pelvis  of  the  kidney,  and 
apparently  formed  by  the  distended  infundibula. 

The  right  kidney  was  healthy,  as  were  also  the  other  abdominal 
organs. 

Diagnosis. — (a)  Pyelitis  loithout  Tumor. — In  the  iirst  stage  of 
the  complaint,  the  presence  of  the  characteristic  epithelium  of 
the  pelvis  and  calices  in  the  urinary  deposit,  generally  suffices 
to  indicate  the  nature  of  the  disease.  When  the  urine  has 
become  purulent,  these  may  still  be  found  mixed  with  the  pus 
corpuscles ;  but  in  more  advanced  cases  this  valuable  sign  is  no 
longer  available,  and  the  source  of  the  discharged  pus  must  be 


468  PYELITIS. 

traced  by  other  indications.  These  indications  are  often  more 
of  a  negative  than  positive  character.  "When  pus  is  discharged 
with  an  acid  urine,  and  signs  of  disease  of  the  iDladder,  prostate, 
and  urethra  are  absent,  the  prima  facie  inference  is,  that  it  comes 
from  the  pelvis  of  the  kidney  :  ^  this  interference  is  strengthened 
almost  to  a  certainty,  if  tenderness  exist  in  either  loin,  or  if 
there  be  any  history  of  antecedent  nephritic  colic. 

It  is  much  easier  to  recognize  the  existence  of  pyelitis  when 
it  stands  alone  than  when  it  coexists  with,  and  perhaps  is  the 
consequence  of,  chronic  disease  of  the  lower  urinary  passages. 
Pyelitis  is  a  common  complication  of  old-standing  cases  of 
cystitis,  enlarged  prostate,  and  urethral  stricture.  In  the 
absence  of  tumor  in  the  flank  it  may  be  impossible,  in  such 
cases,  to  arrive  at  a  positive  certainty  as  to  the  coexistence  of 
pyelitis.  Little  help  can  be  obtained  from  the  character  of  the 
urine,  because  it  bears  the  stronger  impress  of  the  vesical, 
prostatic,  or  urethral  disorder  :  but  a  careful  weighing  of  the 
following  points  will  generally  lead  to  a  correct  conclusion. 
The  upper  urinary  passages  are  likely  to  be  involved  when  the 
quantity  of  pus  is  very  great — two  or  three  ounces  or  more  per 
day ;  when,  with  a  large  discharge  of  pus,  the  urine  is  only 
feebly  ammoniacal ;  when  the  loins  are  painful  on  pressure ; 
and  the  febrile  movement  and  the  decay  of  strength  seem  out 
of  proportion  to  the  vesical  or  urethral  mischief;  lastly,  when 
the  latter  has  been  in  existence  for  several  years. 

(h)  Pyelitis  with  Tumor— Pyonephrosis. — Cases  of  this  class  do 
not  usually  present  much  diagnostic  difficulty.  There  is  an 
elastic  fluctuating  enlargement  on  one  side  of  the  abdomen, 
occupying  the  situation  of  a  renal  tumor,  and  a  great  discharge 
of  pus  with  the  urine.  This  discharge  is  apt  to  vary  from  time 
to  time;  and  the  dimensions  of  the  tumor  are  observed  to  in- 
crease and  decrease  in  inverse  correspondence. 

When  the  outlet  from  the  sac  is  permanently  sealed  the  nature 
of  the  lumbar  tumor  is  much  more  obscure.  It  is  liable  to  be 
mistaken  for  hydronephrosis,  a  hydatid  cyst,  a  perinephritic 
abscess,  or  an  abscess  or  cyst  of  the  spleen,^  or  liver.  The  diag- 
nosis, in  such  a  case,  turns  first  on  the  existence  of  a  tumor  pre- 
senting the  physical  signs  of  a  renal  tumor  {see  Diagnosis  of 
Cancer  of  the  Kidney);  secondly,  on  the  evidence  of  fluidity  of 
its  contents ;  and  thirdly,  on  the  signs  that  that  fluid  is  purulent 
(recurrent  rigors  and  hectic). 

^  For  the  diagnostic  signs  of  the  sources  of  pus  discharged  with  the  urine,  see 
p.  147. 

2  Gaffe  records  a  case  of  pyonephrosis  in  a  Portuguese  physician,  residing  in 
Paris,  which  was  mistaken  for  a  cyst  of  the  spleen.  No  pus  had  ever  appeared  in 
the  urine  ;  indeed,  there  were  no  urinary  symptoms  at  any  time.  Nelaton  punc- 
tured the  supposed  cyst  and  withdrew  4|  litres  of  pus.  The  patient  survived  55 
days.     (Gaz.  des  Hop.,  1855.) 


PROGNOSIS.  469 

Procjnosis. — The  prospects  of  a  patient  suffering  from  pyelitis 
differ  greatly  according  as  one  or  both  sides  are  affected,  arjd 
according  to  the  nature  of  the  exciting  cause. 

Double  pyelitis  arrived  at  the  purulent  stage  is  a  disoi'der  of 
very  grave  consequence,  whatever  may  have  been  its  mode  of 
origin,  and  usually  ]>roves  fatal  in  the  end.  When  the  disease 
is  confined  to  one  side,  the  issue  may  be  favorable,  either  with 
or  without  destruction  of  the  kidney.  Cases  of  this  last  class 
are  not  infrequent :  numerous  examples  have  been  recorded  in 
which  one  kidney  has  been  found,  after  death  from  some  other 
cause,  bearing  the  marks  of  previous  sacculation  and  suppura- 
tion. Sometimes  nothing  is  found  in  the  situation  of  the  kidney 
beyond  the  capsule  of  the  gland  tightly  embracing  a  urinary 
calculus;  in  others,  an  empty  cellular  sac;  in  others,  a  saccu- 
lated pouch  completely  filled  with,  concrete  pus.  An  example 
is  reported  by  KussmauP  in  which  pyonephrosis  was  encountered 
(post-mortem)  apparently  in  an  earl}'  stage  of  obsolescence.  The 
patient  died  of  constitutional  syphilis,  with  lardaceous  liver  and 
spleen,  and  Bright's  degeneration  of  the  left  kidney.  The  right 
kidney  was  converted  into  a  soft,  thick-walled  tumor,  as  large  as 
a  child's  head,  situated  in  the  right  hypochondrium.  It  was 
filled  with  thick,  inodorous  pus;  the  renal  tissue  had  totally  dis- 
appeared. The  sac  had  contracted  adhesions  to  all  the  surround- 
ing parts.  The  ureter  was  adherent  to  the  wall  of  the  sac,  so 
that  the  escape  of  the  pus  was  prevented.  A  probe,  however, 
could  be  passed  along  it  into  the  dilated  pelvis.  The  disease 
was  evidently  of  old  date ;  no  symptoms  (beyond  the  physical 
signs  of  tumor)  referable  to  it  were  observed  during  life ;  and 
the  cause  of  its  production  could  not  be  clearly  made  out  after 
death. 

The  gravity  of  pyelitis  has  a  close  connection  with  the  nature 
of  its  original  cause.  Cancerous  and  tuberculous  pyelitis  in- 
variably prove  fatal  :  the  prognosis  is  almost  equally  hopeless 
when  the  disease  is  secondary  to  enlarged  prostate,  intractable 
disease  of  the  bladder,  or  urethra.  The  prospect  is  more  favor- 
able, though  still  exceedingly  grave,  in  cases  which  follow  preg- 
nancy, or  depend  upon  renal  gravel,  calculus,  or  hydatids. 

"When  pyelitis  is  secondary  to  some  acute  disease  (zymotic 
fevers,  etc.)  it  is  of  very  slight  consequence,  and  speedily  passes 
away  with  the  subsidence  of  the  primary  disorder. 

Rupture  of  the  sac  into  the  thoracic  or  peritoneal  cavities 
is  speedily  fatal.  Rupture  into  the  intestine  generally,  if  not 
always,  proves  ultimately  fatal ;  but  the  sac  may  open  through 
the  loin  with  a  favorable  issue ;  though  this  is  exceptional. 

1  Wiirzb.  Med.  Zeitsclir.,  1863,  p.  43. 


470  PYELITIS. 

Treatment. — The  chief  general  indications  in  the  manage- 
ment of  cases  of  pyelitis  are  :  to  remove  the  exciting  cause,  and 
to  arrest  or  control  the  purulent  discharge. 

When  pyelitis  is  secondary  to  Bright's  disease,  diabetes, 
scurvy,  purpura,  diphtheria,  typhus  or  other  zymotic  fever,  the 
gravity  of  the  primary  disease  so  overshadows  the  secondary 
affection  that  the  latter  rarely  demands  separate  attention.  It 
is  only  in  the  rare  hemorrhagic  examples  when  the  loss  of  blood 
by  the  urine  becomes  threatening,  that  the  internal  administra- 
tion of  astringents  and  styptics  becomes  necessary. 

The  particular  treatment  applicable  to  the  different  species  of 
pyelitis  will  be  found  described  under  the  several  headings  of 
Concretions  in  the  Kidney,  Parasites,  Tubercle,  Cancer,  etc. 

The  following  observations  will  find  their  application  in  those 
cases,  both  acute  and  chronic,  in  which  the  inflammation  of  the 
pelvis  and  infundibula  is  a  leading  feature  of  complaint,  and 
the  source  of  the  more  important  symptoms. 

If  the  attack  be  acute,  and  accompanied  with  pain  in  the 
renal  region,  frequent  and  painful  micturition,  bloody  urine, 
and  fever,  the  loins  should  be  cupped  to  eight  or  twelve  ounces ; 
the  cupping  should  be  followed  up  with  warm  baths  and  hot 
poultices  to  the  loins.  Warm  diluents  should  be  freely  admin- 
istered. Opium  and  other  anodynes  are  sometimes  demanded 
on  account  of  the  intensity  of  the  suffering  and  evidence  of 
spasm  of  the  ureter. 

In  chronic  cases,  when  the  secretion  of  pus  is  profuse,  the 
eflfbrts  of  the  practitioner  must  be  directed  to  lessen  the  dis- 
charge, and  to  bring  the  renal  tumor,  if  there  be  any,  to  a  state 
of  contraction  or  of  obsolescence,  and  throughout  to  keep  up 
the  general  health  to  the  highest  possible  standard. 

Among  the  remedies  which  are  available  to  check  the  dis- 
charge of  pus  are,  the  mineral  acids,  alum,  vegetable  astringents, 
tincture  of  cantharides,  balsamic  and  terebinthine  substances. 
These  last  are  only  applicable  when  the  disease  is  thoroughly 
chronic,  and  a  stimulant  to  the  mucous  membrane  is  required. 

The  metallic  astringents  have  also  been  occasionally  employed 
with  success,  when  other  m.eans  have  failed.  Mosler  relates  the 
following  instance  of  the  good  efifects  of  acetate  of  lead,  in  a 
case  of  uncomplicated  pyelitis  arising  (presumably)  from  cold : 

David  G.,  set.  19,  cutler,  came  under  treatment  in  August,  1861.  In 
the  spring  of  the  year  he  had  been  working  in  a  very  cold  place,  and 
his  illness  commenced  with  a  smarting  pain  in  passing  water.  This  was 
followed  by  the  appearance  of  pus  in  the  urine.  When  the  case  came 
under  observation,  it  was  quite  uncomplicated  ;  the  only  complaint  was 
smarting  in  making  water,  and  a  desire  to  void  it  about  every  hour. 
Compression  of  the  urethra  caused  no  pus  to  appear  at  the  orifice ;  the 
pus  was  thoroughly  mixed  with  the  urine,  giving  the  latter  a  turbid 


TREATMENT.  471 

appearance.  After  standing,  a  layer  of  pus  subsided  to  the  bottom  of 
the  vessel,  about  half  an  inch  thick.  The  microscope  brought  to  view 
pus  corpuscles  and  various  forms  of  epithelial  cells,  some  of  which  were 
fatty.  The  albumen  was  no  more  than  corresj)onded  to  the  amount  of 
pus.  The  reaction  was  acid,  and  continued  so  throughout.  At  first 
vegetable  astringents  in  large  doses  (10  grains  of  tannic  acid  thrice  daily) 
were  employed  ;  then  balsamic  remedies  in  the  form  of  Griffith's  mix- 
ture, etc. ;  then  alkalies  f sod.  bicarb,  .^^iij  daily ).  The  quantity  of  pus 
remained  stationary,  in  spite  of  all  these  remedies ;  but  the  smarting  in 
passing  water  had  mostly  ceased. 

In  the  beginning  of  October,  the  patient  complained  for  the  first  time 
of  pain  in  the  right  lumbar  region.  At  that  time  there  were  blood-cor- 
puscles in  the  urine,  as  well  as  pus  and  epithelium.  The  pus  had  in- 
creased. The  alkalies  were  now  combined  with  the  use  of  warm  baths  ; 
the  blood  soon  disappeared,  and  the  pains  ceased,  but  the  pus  continued 
undiminished. 

On  the  1st  of  January,  1862,  the  use  of  acetate  of  lead  was  com- 
menced in  doses  of  three  grains  three  times  a  day.  At  the  end  of  eight 
days  the  dose  was  increased  to  four  grains  three  times  a  day.  The  effect 
of  the  treatment  on  the  amount  of  pus  was  marked  ;  on  the  tenth  day  the 
quantity  was  visibly  diminished,  and  shortly  afterwards  it  disappeared 
altogether.  Some  months  later  the  patient  presented  himself  again ;  the 
urine  was  found  quite  free  from  pus,  and  the  general  health  blooming. 
These  large  doses  produced  colicky  symptoms  toward  the  end  of  the 
second  week ;  and  there  was  at  the  same  time  a  decided,  though  not 
great,  diminution  in  the  daily  quantity  of  urine. 

The  tincture  of  the  sesquichloride  of  iron  has  sometimes 
proved  of  signal  service,  as  in  the  following  example : 

B.  H.,  a  woman,  set.  51,  was  admitted  under  my  care  into  the  Royal 
Infirmary,  in  December,  1862,  in  a  state  of  extreme  weakness  and  ema- 
ciation. On  examining  the  urine  it  was  found  acid,  loaded  with  pus 
mixed  with  some  blood.  Micturition  was  frequent  with  smarting  pain. 
Careful  and  repeated  exploration  of  the  bladder  failed  to  detect  a  stone. 
The  right  kidney  was  painful  on  pressure,  and  the  anamnesis  disclosed 
obscure  history  of  renal  calculus.  There  was  no  fulness  in  the  loin. 
The  daily  quantity  of  pus  was  estimated  at  three  ounces.  The  deposit 
in  the  urine  contained  no  cellular  elements  except  pus  and  blood. 

She  was  first  put  on  a  mild  alkaline  treatment,  with  generous  diet, 
and  six  ounces  of  wine.  No  improvement  followed  ;  she  continued  to 
lose  ground,  and  was  unable  to  leave  her  bed  ;  the  tongue  became  dry 
at  times,  and  symptoms  of  severe  hectic  showed  themselves.  The  alka- 
lies were  then  discontinued  ;  and  30  drops  of  tincture  of  steel  in  h  wine- 
glass of  water,  administered  three  times  a  day ;  the  wine  was  increased 
to  10  ounces.  This  treatment  was  continued  for  many  weeks,  and  gradual 
amendment  set  in.  Blood  disappeared  wholly  from  the  urine,  and  the 
discharge  of  pus  was  reduced  to  less  than  half  an  ounce.  The  general 
health  improved  proportionally;  and  in  March,  1863,  the  patient  was 
able  to  leave  the  hospital  in  a  fair  w^ay  of  recovery.  She  afterwards 
presented  herself  among  my  out-patients  from  time  to  time  for  some 


472  PYELITIS. 

months,  and  steadily  gained  strength.  At  length  she  went  to  her  work 
(weaving),  and  I  heard  nothing  more  of  her  until  April,  1864.  All  her 
symptoms  had  returned  in  great  severity  some  weeks  before.  She  de- 
clined to  comply  with  my  recommendation  to  enter  the  Infirmary,  and, 
four  weeks  after,  I  heard  of  her  death. 

Among  the  general  means  designed  to  keep  up  the  vigor  of 
the  system,  the  most  important  are  cod-liver  oil,  quinine,  nour- 
ishing diet,  and,  above  all,  change  of  air.  Sea-side  localities 
are  preferable,  and  even  sea-bathing  may  be  recommended,  if 
the  patient's  strength  permit. 

When  renal  tumor  exists,  it  may  be  treated  like  abscesses  in 
other  situations,  by  incision  and  free  drainage,  with  antiseptic 
precautions,  and  in  this  way  a  complete  cure  may  be  eiFected. 
As  a  rule,  however,  it  is  not  advisable  to  take  any  steps  with  a 
view  to  procure  evacuation  of  the  sac  through  the  integuments, 
unless  there  be  decided  indications  of  pointing.  It  must  be 
remembered  that  there  is  always  a  chance  (supposing  the  dis- 
ease to  be  confined  to  one  side)  that,  with  rest  and  patience,  the 
pus  may  become  inspissated,  and  the  abscess  pass  into  a  perma- 
nently obsolescent  state ;  or  that  gradual  emptying  of  the  sac 
may  take  place  with  final  atrophy  of  the  renal  tissue.  The 
advantages  of  an  expectant  treatment  are  strikingly  illustrated 
in  the  following  case,  recorded  by  Henninger : 

The  patient  received  a  blow  on  the  left  lumbo-renal  region  in  1848. 
Obscure,  persistent  renal  pains  followed  the  accident.  Three  years  after, 
the  patient  had  nephritic  colic  on  the  left  side,  which  recurred  in  periodi- 
cal paroxysms,  resembling  ague.  In  1852,  the  attacks  recurred  about 
every  three  days ;  they  were  followed  by  the  discharge  of  a  highly 
purulent  urine.  Mixed  with  the  pus  were  found  epithelial  cells  and 
crystalline  deposits.  A  tense  elastic  tumor  was  discovered  in  the  left 
hypochondrium,  extending  as  far  as  the  vertebral  column.  After  a 
paroxysm,  and  discharge  of  pus  with  the  urine,  this  tumor  was  only 
doubtfully  perceptible,  but  in  exploring  along  the  course  of  the  ureter, 
a  body  as  large  as  a  nutmeg  was  discovered  in  the  iliac  fossa,  in  the 
track  of  the  ureter.  The  nature  of  the  case  was  now  clearly  made  out 
to  be  calculous  pyelitis  with  tumor.  The  advice  of  M.  Schutzenberger 
was  to  establish  a  fistulous  opening  in  the  renal  region  with  a  view  to 
provide  a  safe  outlet  for  the  pus,  and  thus  relieve  the  neuralgic  parox- 
ysms. On  consulting  with  Prof.  Sedillot,  it  was  agreed  to  wait  the 
progress  of  events,  in  the  hope  that  the  renal  tissue  would  be  gradually 
absorbed,  and  the  kidney  reduced  to  a  membranous  pouch,  which,  on  the 
cessation  of  the  secretion  of  urine,  might  eventually  contract.  These 
hopes  were  realized.  A  merely  palliative  treatment  was  adopted  ;  and 
six  months  afterwards  the  patient  saw  an  end  to  his  sufferings ;  he  has 
continued  since  in  uninterrupted  health.^ 

1  Henninger,  These  do  Strasbourg,  1862. 


TREATMENT.  473 

There  are  cases,  indeed,  in  which  the  distention  of  the  sac 
becomes  so  great,  that  the  peril  of  rupture  into  the  peritoneum 
exceeds  the  risk  of  making  an  opening  through  the  integu- 
ments. 

The  radical  treatment  of  unilateral  pyonephrosis  by  removal 
of  the  kidney,  although  several  successful  cases  are  reported, 
must  yet  be  considered  as  subjudice.^ 

'^  See  the  discussion  in  the  Clinical  Society  of  London.    Lancet,  1882,  i.  p.  •'>27. 


CHAPTER  YII. 

CONCRETIONS  IN  THE  KIDNEYS. 

Close  examination  of  sections  of  the  kidney  sometimes  reveals 
the  existence  of  numerous  yellowish  or  brownish  strise,  running 
from  the  papillte  toward  the  base  of  the  pyramids.  These  are 
due  to  the  precipitation  of  amorphous  urates  within  the  straight 
canals.  This  is  generally  only  a  post-mortem  phenomenon : 
the  cooling  of  the  body  after  death  diminishes  the  solubility  of 
the  urates,  and  causes  them  to  be  precipitated  in  the  uriniferous 
tubes. 

In  newly  born  infants  who  have  breathed,  such  strise  are  very 
frequently  found,  especially  when  death  occurs  between  the 
second  and  fourteenth  days  after  birth.  Virchow  is  of  opinion 
that  such  a  deposit  is  due  to  the  excessive  excretion  of  urates 
due  to  the  increased  metabolism  of  tissue  consequent  upon  the 
establishment  of  respiration.  In  a  few  cases,  however,  the 
deposit  has  been  found  in  children  who  have  never  respired 
(Hoogeweg  and  Martin,  Ebstein). 

A  similar  precipitation  may,  however,  occur  during  life,  and 
constitute  the  first  link  in  a  chain  of  consequences  which  leads, 
eventually,  to  the  production  of  urinary  gravel  and  stone. 
Uric  acid  and  oxalate  of  lime  may  also  be  deposited  in  the  same 
manner,  and  furnish  the  nuclei  of  future  calculi.  *  Such  concre- 
tions may  be  permanently  impacted  in  the  uriniferous  ducts, 
and  render  these  impervious,  and  themselves  cease  to  grow ;  or 
they  lodge  in  diverticula  or  pouches  connected  with  the  ducts, 
and  increase  in  size  amid  the  renal  tissue ;  or,  lastly,  and  most 
frequently,  they  are  rolled  down  along  the  ducts  by  the  stream 
of  urine,  and  deposited  in  the  infundibula  and  pelvis  of  the 
kidney ;  and  even  many  thousands  of  minute  calculi,  formed  in 
this  manner,  may  be  encountered  after  death,  in  these  situations 
(see  case  of  J.  R.,  p.  412).  Agglomerations  of  larger  size  may 
begin  in  the  same  way,  or  the  precipitation  may  first  occur  in 
the  infundibula  and  pelvis. 

In  number,  size,  and  shape,  renal  concretions  present  the 
greatest  diversities.  A  kidney  may  contain  only  one  concretion, 
three  or  four,  or  several  hundreds.  In  size  they  vary  from  a 
pin's  head,  or  a  hemp-seed,  to  a  horse-bean;  and  if  a  concre- 
tion become  permanently  lodged  in  the  pelvis  or  its  appendages, 
it  may  go  on  increasing  to  a  weight  of  several  drachms  or 


SYMrTOMS.  475 

ounces.  Such  a  calculus  ih  UHually  moulded  to  the  divisions 
of  the  pelvis,  and  assunies  various  i^rotesque,  branched,  or  arbo- 
raceous, forms. 

The  cwniomical  changes  produced  by  renal  concretions  are, 
congestion  of  the  kidneys,  abscesses,  pyelitis,  pyonephrosis,  and 
hydronephrosis.  These  are  considered  under  their  respective 
headings. 

Symptoms. — The  existence  of  concretions  in  the  kidney  is 
usually  indicated  by  an  aching  pain  in  the  loins,  occasionally 
rising  into  violent  paroxysms  (nephritic  colic).  This  pain  is 
characterized  by  its  tendency  to  shoot  along  the  course  of  the 
ureters  down  to  the  testicles  and  the  inside  of  the  thighs;  it  is 
also  commonly  attended  with  a  sense  of  faintness,  nausea,  or 
even  vomiting.  The  urine,  in  these  cases,  is  voided  with  undue 
frequency,  often  with  pain  at  the  end  of  the  penis,  and  it  is  apt 
to  contain  blood,  pus,  and  epithelium  from  the  pelvis  of  the 
kidney. 

The  colicky  paroxysms  are  determined  by  dislodgement  of 
the  concretions  from  one  of  the  infundibula  into  the  cavity  of 
the  pelvis,  or  from  one  part  of  the  pelvis  to  another;  but  the 
most  severe  attacks  are  caused  by  the  passage  of  it  into  the 
ureter. 

The  descent  of  a  calculus  along  the  ureter  into  the  bladder  is 
productive  of  very  distinctive  symptoms.  The  patient  is  sud- 
denly seized  with  intense  pain  in  the  region  of  the  affected  kid- 
ney, accompanied  with  a  deadly  faintness,  sometimes  with  cramp 
and  sickness.  The  pain  radiates  in  various  directions,  but  chiefly 
along  the  ureter  to  the  bladder,  scrotum,  end  of  the  penis,  and 
the  inside  of  the  thigh.  The  testicle  is  retracted ;  there  is  in- 
cessant desire  to  make  water,  but  the  flow  of  urine  is  either 
partially  or  wholly  suppressed.  In  the  former  case,  the  urine  is 
high-colored,  often  mixed  with  blood,  and  voided  in  drops  with 
burning  pain.  Violent  and  frequent  vomiting  follows ;  the  skin 
is  covered  with  a  cold  sweat;  there  is  constant  restlessness;  the 
patient  tosses  from  side  to  side,  and  assumes  in  succession  a 
score  of  different  positions  in  the  hope  of  relief.  If  the  symp- 
toms are  not  speedily  relieved,  a  febrile  movement  is  produced, 
which,  sometimes,  attains  a  high  degree,  with  hot  skin,  quick 
pulse,  and  incessant  thirst. 

After  these  symptoms  have  continued  a  certain  time — it  may 
be  hours,  it  may  be  days — relief  comes,  often  quite  suddenly. 
The  patient  feels  something  drop  into  the  bladder,  and,  all  at 
once,  his  agony  is  past.  Sometimes,  how^ever,  the  concretion 
fails  to  clear  the  ureter,  and  becomes  impacted  in  some  part  of 
its  course.  In  this  case,  the  subsidence  of  the  symptoms  is 
more  gradual,  and  less  complete.  In  other,  fortunately  still 
rarer,  instances  the  opposite  ureter  has  already  been  rendered 


476  CONCRETIONS    IN    THE    KIDNEYS. 

impervious  by  the  impaction  of  a  calculus  on  some  previous 
occasion,  and  the  blocking  up  of  the  hitherto  open  channel  is 
followed  by  total  anuria,  which  leads  to  a  rapidly  fatal  issue. 
{8ee  Suppression  of  Urine.) 

Renal  calculi  are  sometimes  wholly  latent.  They  may  even 
attain  a  large  size,  and  destroy  extensive  portions  of  the  gland, 
without  betraying  their  presence  by  a  single  symptom.  Or, 
again,  renal  symptoms  may  exist  for  a  longer  or  shorter  period, 
and  then  wholly  and  finally  cease.  This  latter  event  may 
occur  under  two  circumstances;  either  the  concretion  completely 
occludes  the  ureter,  and  determines  gradual  atrophy  of  the 
kidney,  or  it  becomes  encysted  in  a  lateral  pouch  or  diverticu- 
lum, and  ceases  to  impede  the  flow  of  urine  and  to  irritate  the 
mucous  membrane.^ 

The  Diagnosis  of  a  calculus,  or  calculi,  in  the  kidney  or  pelvis 
(except  in  latent  cases)  is  not  generally  attended  with  much  dif- 
ficulty. The  locality,  distribution,  and  paroxysmal  recurrence 
of  the  pains,  with  the  pyelitic  characters  of  the  urine,  are  usually 
sufficient  to  indicate  the  cause  of  suffering.  Neuralgia  of  the 
lower  intercostal  and  abdominal  nerves  sometimes  presents 
great  severity,  and  a  paroxysmal  character.  It  is  distinguished 
from  renal  colic  by  the  absence  of  blood,  pus,  and  transitional 
epithelium  in  the  urine.  More  difficult  to  distinguish  are  those 
cases  in  which  nephritic  colic  is  produced  by  the  impaction  of 
blood-clots  or  hydatids  in  the  ureter ;  indeed,  absolute  certainty 
cannot  often  be  obtained  in  these  cases  until  the  appearance  of 
gravel,  hydatids,  or  clots  in  the  urine  sets  the  question  at  rest. 
The  antecedents  of  the  patient  sometimes  throw  an  important 
light  on  the  diagnosis,  and  a  knowledge  of  the  nature  of  a  fore- 
going attack  will  furnish  a  key  to  an  existing  one. 

In  the  absence  of  colicky  paroxysms — where  the  symptoms 
consist  only  of  obscure  lumbar  pains  and  slight  disturbances  of 
micturition,  careful  and  repeated  examination  of  the  urinary 
deposit  becomes  the  principal  means  of  arriving  at  a  precise 
diagnosis.  If  the  symptoms  be  due  to  calculus,  the  deposit  will, 
in  all  probability,  contain  scattered  blood-disks  and  spindle- 
shaped,  tailed,  and  irregular  epithelial  cells  from  the  upper 
urinary  passages.  These  may  be  accompanied  with  pus  corpus- 
cles, and  minute  agglomerations  of  uric  acid,  dumb-bells  of 
oxalate  of  lime,  or  some  other  form  of  calculous  deposit  {see  Fig. 
58).  These  unnatural  conditions  of  the  urine  are  intensified  by 
violent  exercise,  and  diminished  or  altogether  suppressed  when 
the  patient  maintains  a  state  of  rest. 

1  In  one  ca=e  the  calculus  was  discharged  externally  through  a  fistulous  opening 
in  the  loin.  (Path  Trans.,  vol.  xxvi.  p  128.)  In  another  case,  the  stone  worked 
its  way  into  the  muscles  and  remained  there  for  seven  years,  when  it  was  removed 
by  operation.     (Amer.  Journ.  Med.  Sciences,  April,  1881.) 


TREATMENT. 


477 


The  Treatment  of  renal  concretions  must  be  modified  accord- 
ing to  the  existing  symptoms  and  the  anatomical  changes  wliich 
may  be  inferred  to  have  taken  place  in  the  kidneys. 

During  the  paroxysms  of  renal  colic,  the  remedies  indicated 
are  warm  baths,  emollient  enemata,  cupping  the  loins,  and,  in 
highly  sthenic  cases,  venesection.  The  dolorous  spasm  of  the 
ureter  must  be  combated  by  free  administration  of  opium. 
This  drug  is  freely  tolerated  in  cases  of  this  class,  and  full  doses 
should  be  repeated  until  the  system  is  plainly  brought  under  its 

Fig.  58. 


Octahedra  and  dumb-bells  of  oxalate  of  lime  embedded  in  a  mucoid  flake — in  the  freshly  voided  urine 
from  a  case  of  renal  gravel. 


influence.  When  the  irritability  of  the  stomach  is  such  as  to 
prevent  the  absorption  of  the  drug,  it  should  be  introduced  per 
rectum  or  by  subcutaneous  injection.  Belladonna  may  be  sub- 
stituted where  opium  disagrees.  The  secretion  of  the  urine 
should  be  encouraged  by  warm  demulcent  drinks;  hot  poultices 
should  be  applied  to  the  loins  or  abdomen,  as  the  local  symptoms 
indicate. 

Change  in  the  position  of  the  patient  sometimes  sufiices  to 
dislodge  a  calculus  which  lies  upon,  but  has  not  become  fully 
engaged  in,  the  orifice  of  the  ureter.  Manipulation  of  the  abdo- 
men in  the  course  of  the  ureters  may  also  facilitate  the  descent 
of  the  concretion.  Sir  James  Simpson  witnessed  relief  follow 
complete  inversion  of  the  hody.^ 

In  the  intervals  of  the  nephritic  attacks,  or  when  none  exist, 
the  treatment  must  be  conducted  either  with  a  view  to  dissolve 
the  concretion  [see  Solvent  Treatment  of  Urinary  Calculi)  or 

1  Edin.  Med.  Journ.,  1858-9,  p.  76. 


478  coNCEETiojsrs  in  the  kidneys, 

according  to  the  rules  laid  down  for  the  management  of  chronic 
pyelitis.  When  abscesses  form,  or  pyo-  or  hydronephrosis  is 
established,  the  modes  of  treatment  de'scribed  under  these  head- 
ings must  "be  followed  out. 

Incising  the  kidney  through  the  loins,  and  extracting  the 
offending  calculi  through  the  wound  (nephrotomy),  is  a  method 
of  treatment  as  old  as  the  time  of  Hippocrates.  It  is,  however, 
not  recommended  by  modern  surgeons,  except  when  suppura- 
tion has  taken  place,  and  the  abscess  is  manifestly  pointing  in 
the  loins.  When  such  an  abscess  is  opened,  exploration  should 
be  made  with  a  probe,  and  if  concretions  are  detected  thereby, 
cautious  endeavors  may  be  made  to  remove  them  by  suitable 
instruments.  (Hevin  and  Yelpeau — Oldheld,  "  These  de  Paris," 
1863;  see,  also,  "  Gaz.  Hebd.."  1867,  p.  767;  "  Lancet,"  1882,  i. 
p.  184;  1883,  i.  p.  278.) 

Extirpation  of  the  kidney,  or  nephrectomy,  is  an  operation  which 
has  been  performed  several  times  in  recent  years.  Eight  cases 
are  collected  in  the  "American  Journal  of  Medical  Sciences" 
for  January,  1873,  p.  277.  Six  died  and  two  recovered.  An- 
other case  of  recovery  after  excision  of  an  injured  kidney  is 
recorded  by  Brandt.  ("  Wien.  Med.  Woch.,"  1873,  and  "  Ed. 
Med.  Journ.,"  May,  1884.)  Dr.  Campbell  records  a  case  of  cystic 
tumor  of  the  left  kidney  which  was  mistaken  for  an  ovarian  cyst, 
and  removed,  together  with  the  kidney,  by  operation.  The 
patient  slowly  recovered.  ("  Ed.  Med.  Journ.,"  July,  1874.) 
Still  more  recent  successful  cases  of  nephrectomy  will  be  found 
mentioned  in  the  "Lancet,  1882.  i.  p.  1070;  1882,  ii.  p.  568, 
p.  892;  1883,  i.  p.  423,  p.  424,  p.  548,  p.  963;  while  the  present 
position  of  renal  surgery  may  be  gathered  from  the  discussions 
in  the  Clinical  Society  of  London  reported  in  the  "  Lancet," 
1882,  i.  p.  527,  and  ii.  p.  942,  and  in  the  Medico-Chirurg. 
Society ;  see  "  Med.  Times  and  Gaz.,"  1883,  i.  p.  624. 


CHAPTER  YJII. 

HYDRONEPHROSIS. 

When  any  impediment  exists  to  the  flow  of  urine  from  the 
kidneys  the  secretion  accumulates  behind  the  obstruction  and 
distends  the  parts  above.  The  tirst  effects  of  the  pressure  of 
the  accumulated  urine  are  felt  in  the  higher  portions  of  the 
ureter  and  the  pelvis  of  the  kidney  :  these  parts  become  dilated. 
Then  the  renal  substance  is  compressed,  and  becomes  partially 
or  wholly  atrophied  and  absorbed ;  so  that  the  organ  is  at  length 
hollowed  out  into  a  pouch  or  bag,  consisting  of  the  fibrous  cap- 
sule of  the  kidney.  When  these  changes  are  associated  with 
suppuration  of  the  lining  membrane  the  condition  termed  pyo- 
nephrosis (already  described)  is  produced.  But  in  a  consider- 
able number  of  instances  the  obstruction  is  unaccompanied  with 
purulent  formation ;  the  distention  proceeds  painlessly  and 
gradually.  This  is  the  case  when  the  impediment  arises  from 
some  congenital  malformation  ;  also  when  it  is  incomplete,  or  is 
established  by  degrees.  To  this  condition  the  terms  "  dropsy  of 
the  kidney"  and  "  hydrorenal  distention"  have  been  applied; 
but  both  designations  have  given  place  to  the  term  hydrone- 
phrosis, introduced  by  Rayer,  and  now  generally  adopted. 

Morbid  Anatomy. — Some  years  ago  I  exhibited  to  the  Man- 
chester Medical  Society  a  typical  example  of  what  may  be  called 
a  fully  developed  hydronephrosis.  It  consisted  of  a  large  mem- 
branous bag,  13  inches  long  by  8  inches  broad.  It  represented 
the  right  kidney  of  a  woman,  who,  during  life,  was  supposed  to 
be  the  subject  of  ovarian  dropsy.  She  had  been  twice  tapped 
under  that  impression,  and  died  of  peritonitis  after  the  second 
operation.  It  proved,  after  death,  to  be  the  right  kidney  and 
pelvis  monstrously  dilated.  When  filled  with  fluid  the  cyst  had 
a  lobed  or  sacculated  exterior,  like  an  enormous  colon.  The 
ureter  was  incorporated  with  the  posterior  wall  of  the  cyst,  and 
opened  obliquely  into  the  dilated  pelvis,  with  a  valvular  ari'ange- 
ment  resembling  that  at  the  entrance  of  the  ureter  into  the 
bladder.  The  channel  was  pervious  to  a  probe ;  but  the  valve- 
like deformity  of  its  orifice  (evidently  congenital)  prevented  the 
free  escape  of  urine. 

On  cutting  open  the  cavity  a  complete  fibrous  skeleton  of  the 
kidney  was  disclosed  {see  diagram.  Fig.  59).  The  pelvis  was 
dilated  to  the  size  of  a  large  cocoanut,  and  formed  a  sort  of 


480  HYDRONEPHROSIS. 

antrum^  in  tlie  interior  of  which  seven  smooth  rounded  openings 
were  situated,  large  enough  to  admit  the  Uttle  finger.  Each  of 
these  openings  led  into  a  rudely  pyramidal  chamber,  the  bulging 
base  of  which  corresponded  to  one  of  the  external  lobulations. 
These  chambers  were  separated  from  each  other  by  strong 
membranous  septa ;  but  they  communicated  indirectly  with  each 

Fig.  59. 


Diagram  of  a  fully  developed  hydronephrosis. 

other  through  the  openings  into  the  enlarged  pelvis.  Not  a 
particle  of  kidney  substance  existed  in  any  part;  but  three  flat- 
tened fibro-cartilaginous  nodules  were  found  embedded  in  the 
outer  wall  of  the  sac.  The  fibrous  membrane  which  composed 
the  pouch  and  septa  was  exceedingly  tough  and  strong,  much 
resembling  the  dura  mater.  The  outer  membrane  evidently 
consisted  of  the  thickened  and  hypertrophied  tunica  propria, 
and  was  continuous  with  the  fibrous  structure  of  the  dilated 
pelvis.  The  septa  corresponded  to  some  of  the  embryonal  divi- 
sions of  the  kidney ;  and  the  circular  openings  represented  the 
chief  divisions  of  the  pelvis. 

From  this  type  there  are  many  variations.  The  sac  may  not 
be  nearly  so  large :  it  may  not  exceed  the  dimensions  of  the 
healthy  organ :  it  may  be  even  smaller.  The  chambers  vary 
much  in  depth,  and  in  number;  there  may  be  only  two  or  three  ; 
or  the  whole  sac  may  consist  of  only  a  single  cavity.  The  cyst 
may  be  composed  in  varying  proportions  of  expanded  pelvis  and 
dilated  kidney  :  sometimes  the  expansion  is  almost  confined  to 
the  former,  which  is  transformed  into  a  globular  swelling  occu- 
pying the  hilus  of  the  kidney.  The  absorption  of  the  secreting 
tissue  is  not  usually  complete.     The  stagnating  urine  exerts  its 


MOBBID    ANATOMY.  481 

pressure  in  the  first  instance  upon  the  i)api]]8e  wljich  boconio 
flattened,  and,  as  it  were,  eit'aced ;  then  the  bodies  of  tlie  i)yra- 
mids  are  compressed  and  gradually  atrophied;  lastly  the  cortex 
is  encroached  on,  more  and  more,  until  it  is  reduced  to  mere 
islets  of  reddish  tissue  on  the  membranous  parietes;  and,  at 
lengtli,  if  life  be  sufKciently  prolonged,  these  disappear,  and  not 
a  vestige  of  tlie  glandular  tissue  remains. 

When  only  one  kidney  is  involved,  a  compensating  hyper- 
trophy of  the  opposite  organ  takes  place,  and  the  urinary  func- 
tion goes  forward  unhindered  so  long  as  the  latter  continues 
sound,  and  its  channels  of  excretion  free.  There  is  nothing 
astonishing  in  this ;  but  it  is  very  unexpected  to  find  that  de- 
struction of  tlie  secreting  tissue  may  proceed  to  an  extreme 
degree  in  both  kidnej-s  without  evoking  marked  symptoms  of 
deranged  urine  secretion.  A  person  may  apparently  exist  for  a 
time  with  the  two  kidneys  wholly  reduced  to  membranous  sacs 
devoid  of  any  tubular  structure.  In  Dr.  Strange's  case,  already 
cited  (p.  232),  in  which  profuse  diuresis  had  existed  from  infancy, 
not  a  particle  of  renal  substance  could  be  detected  in  the  renal 
sacs  after  death,  though  life  had  been  protracted  to  the  age  of 
eighteen  years.  Another  equally  remarkable  case  is  related  by 
Faber,'  The  subject  of  it  was  a  little  boy,  who  had  been  ventri- 
cose  from  birth,  and  in  weak  health.  The  urine  generally  pre- 
sented nothing  abnormal ;  but  on  two  or  three  occasions  the  boy 
suffered  from  severe  paroxysms  of  strangury,  with  symptoms 
resembling  those  of  stone  in  the  bladder.  JSTotwithstanding 
these  drawbacks,  the  boy  was  in  better  health  the  last  year  of 
his  life  than  he  had  been  for  the  previous  four  years,  and  was 
able  to  go  about.  When  he  had  reached  the  age  of  5i^  years  he 
fell  from  a  chair  and  died  suddenly  in  consequence.  The  autopsy 
revealed  the  following  state  of  the  urinary  organs.  Both  kid- 
neys were  converted  into  large  pouches  or  sacs,  containing  no 
trace  of  kidney  substance.  The  renal  pelves  were  likewise 
greatly  distended,  and  the  ureters  so  completely  resembled  the 
small  intestine  that  the  dissector  held  them  several  times  in  his 
hand  in  the  belief  that  they  were  a  coil  of  intestine.  The 
bladder  contained  a  little  turbid  urine  ;*  its  walls  were  greatly 
thickened.  There  was  no  disease  of  the  prostate,  neck  of 
bladder,  nor  urethra.  The  entrances  from  the  bladder  into  the 
dilated  ureters  were  sufficiently  open. 

In  these  and  similar  cases  the  atrophy  of  the  secreting  tissue 
had  doubtless  been  going  on  slowly  and  progressively,  from  the 
time  of  birth.  It  cannot  be  assumed  that  complete  sacculation 
of  the  kidneys  and  total  absence  of  renal  tissue  existed  from 
birth ;  for,  as  was  pointed  out  by  Eayer,  infants  with  congenital 

1  Wiirtz.  Correspondenz-Blatt,  Bd.  xii.  266. 
31 


482  HYDRONEPHROSIS. 

double  hydronephrosis  are  not  viable.  Life  is  probably  eked 
out  in  such  cases  by  the  vicarious  activity  of  the  skin  and  bowels, 
which  undertake  some  portion  of  the  depurative  functions  prop- 
erly belonging  to  the  kidneys.  Death  commonly  takes  place, 
in  cases  of  this  class,  quite  suddenly — sometimes  with  violent 
ursemic  phenomena. 

Of  52  cases  collected  by  me,  the  hydronephrosis  was  confined 
to  one  kidney  in  32  instances,  and  affected  both  (double  hydro- 
nephrosis) in  20  cases.  When  the  hydronephrosis  was  single, 
the  right  side  was  more  frequently  affected  than  the  left  (^19 
right,  and  13  left). 

Hydronephrosis  sometimes  attains  enormous  dimensions;  and 
fills  the  abdomen  w^ith  a  soft  fluctuating  intumescence,  reaching 
from  the  borders  of  the  ribs  to  the  pubes.  Eayer  cites  an  in- 
stance in  .which  sixty  pounds  of  fluid  were  withdrawn  from  the 
sac.  But  the  most  extraordinary  example  which  I  have  dis- 
covered is  the  following,  related  by  Mr.  Samuel  Glass  in  the 
Philosophical  Transactions  for  1747  : 

Mary  Nix  had  been  remarkable  all  her  life  for  the  preternatural  size 
of  her  belly.  Her  mother  stated  that  her  daughter  was  born  dropsical ; 
t)ut  otherwise  she  proved  healthy;  and,  notwithstanding  the  steady 
increase  in  the  size  of  the  abdomen,  she  lived  to  be  near  23  years  of  age. 

She  is  described  as  a  tall  and  well-proportioned  woman,  except  for  the 
enormous  size  of  her  belly;  and,  for  one  of  so  unwieldy  a  bulk,  to  have 
been  brisk  and  active.  The  menses,  which  appeared  at  the  usual  time 
of  life,  continued  regular  until  within  eight  months  of  her  death.  The 
only  complaint  was  of  a  pain  occasionally  felt  in  making  water. 

On  the  suppression  of  the  catamenia,  there  succeeded  a  certain  amount 
of  dyspnoea,  loss  of  appetite,  and  emaciation,  with  swelling  of  one  of 
the  legs,  and  ulcerations.  These  symptoms  gradually  increased  until 
her  death. 

On  taking  the  dimensions  of  her  body  before  dissection,  the  circum- 
ference of  the  abdomen  was  found  to  be  just  six  feet  four  inches,  and 
from  the  xiphoid  cartilage  to  the  os  pubis  she  measured  four  feet  and 
half  an  inch  !  The  cutaneous  vessels  distributed  on  the  abdomen  were 
remarkably  large. 

The  thorax  being  laid  open,  the  diaphragm  was  observed  to  be  forcibly 
protruded  into  that  cavity.  The  base  of  the  heart  lay  under  the  right 
clavicle,  and  its  apex  on  the  most  convex  part  of  the  diaphragm ;  which 
convexity  advanced  as  high  as  the  third  rib.  The  lungs  were  surpris- 
ingly small,  scarcely  exceeding  in  magnitude  those  of  a  new-born  child. 
When  the  abdomen  was  opened  a  vast  cyst  was  displayed,  from  which 
30  gallons  of  a  light,  coffee-colored,  limpid  fluid  were  withdrawn.  The 
fluid  was  not  in  the  least  fetid.  In  figure,  color,  thickness,  and  magni- 
tude, this  enormous  bag  very  much  resembled  the  uterus  of  a  cow  at  the 
end  of  gestation.  The  whole  inside  was  scabrous,  and  looked  as  if  par- 
boiled, and  here  and  there  was  observed  a  small  quantity  of  a  cofiee- 
colored  sediment.     On  the  left  interior  part  was  discovered  the  orifice 


MORBID    ANATOMY.  483 

of  a  duct  (ureter)  which  opened  obli()uely  into  the  cavity  oi"  the  sac, 
and  would  easily  admit  a  large  goosequill.  From  this  opening  the 
tube  advanced  about  twelve  inches  between  the  membranes  of  the  bag 
obliquely  upwards,  and  towards  the  right,  from  whence  it  was  deflected 
downwards  and  passed  between  the  fold  of  the  broad  ligament  into  the 
bladder.  .The  abdominal  viscera  were  thrust  aside  in  various  directions. 
The  left  kidney  and  ureter  were  healthy. 

The  fluid  contents  of  hydronephrotic  cysts  are  generally 
altered  urine.  Urea,  uric  acid,  as  well  as  the  alkaline  and 
earthy  urinary  salts,  have  been  found  therein.  Prout  detected 
urea  and  uric  acid  in  the  contents  of  a  double  hydronephrosis 
from  a  stillborn  infant.  Generally  speaking,  the  fluid  is  much 
more  watery  than  ordinary  urine ;  and  sometimes  the  organic 
urinous  matters  only  exist  in  traces.  The  fluid  may  be  variously 
colored ;  it  may  contain  a  little  blood,  pus,  and  epithelium,  and 
it  is  nearly  always  more  or  less  albuminous. 

In  the  following  two  cases  the  contents  of  the  cyst  consisted 
of  a  substance  resembling  colloid  material.  The  flrst  is  de- 
scribed by  Dickinson  : 

The  patient  was  an  old  woman  of  seventy.  For  twelve  years  she  had 
perceived  a  tumor  in  the  left  hypochondrium,  which  at  length  filled  the 
belly.  Constipation  alternated  with  diarrhoea.  The  patient  stated  that 
she  occasionally  passed  "  nasty  stuff"  by  the  urethra,  and  that  the  tumor 
diminished  in  size  for  a  time  after  that  occurrence.  She  at  length  died 
of  pneumonia.  The  left  kidney  was  found  converted  into  a  large  sac 
about  a  foot  long,  divided  by  septa  into  compartments.  These  com- 
partments were  filled  with  a  gelatinous  substance,  which,  under  the 
microscope,  presented  the  usual  appearances  of  colloid  matter.  It  lay, 
however,  quite  loose  in  the  cyst,  altogether  unattached  to  the  parietes. 
There  was  no  obstruction  whatever  found  in  the  ureter,  nor  in  any  part 
of  the  urinary  channels.  Dickinson  supposed  that  an  obstruction — 
probably  from  a  calculus — existed  at  some  previous  period,  which  led  to 
sacculation  of  the  kidney ;  and  that  the  colloid  matter  was  deposited 
subsequently.     (  "  Path  Soc.  Trans.,"  vol.  xiii.  p.  137.) 

The  second  case  is  reported  by  Prof.  Dumreicher,  of  Vienna, 
and  is  remarkable  in  many  ways  : 

A  girl  of  13  had  observed  a  swelling  in  the  abdomen  from  her  tenth 
year.  This  grew  to  an  enormous  size ;  the  circumference  of  the  aTado- 
men,  which  was  uniformly  distended,  measured  44  inches.  The  percus- 
sion sound  was  dull,  except  over  a  space  of  four  square  inches  on  the 
left  side  below  the  navel.  Fluctuation  was  perceived  over  the  swelling. 
Prof.  Skoda,  under  whose  care  the  girl  first  came,  diagnosticated  an 
ovarian  cyst ;  but  he  pointed  out  the  possibility  of  hydronephrosis.  The 
case  then  passed  to  the  care  of  Prof.  Dumreicher,  who,  on  account  of 
the  dyspnoeal  distress,  punctured  through  the  abdominal  wall,  and  with- 


484  HYDRONEPHEOSIS. 

drew  18  quarts  of  a  colloidal  brown-colored  fluid.  The  circumference 
of  the  belly  now  fell  to  30  inches,  and  the  relief  to  the  patient  was  great. 
Six  weeks  later,  16  quarts  more  were  withdrawn ;  and  an  injection  com- 
posed of  one  ounce  of  tincture  of  iodine,  in  4  ounces  of  water,  with  a 
drachm  of  iodide  of  potassium,  was  introduced  into  the  cyst.  This  pro- 
•oeeding  proved  of  no  effect.  In  about  a  month  14  quarts  more  were 
•evacuated,  and  the  injection  repeated.  Severe  iodism  followed,  and 
continued  for  a  couple  of  days.  The  patient  then  rapidly  improved, 
and  left  the  hospital.  In  about  three  months  she  returned,  larger  than 
■ever.  The  belly  now  measured  462"  inches,  and  the  breathing  was 
much  embarrassed ;  the  heart's  apex  beat  in  the  third  interspace.  In 
the  course  of  the  succeeding  five  months  the  patient  was  tapped  four 
times,  and  an,  aggregate  quantity  of  37  quarts  of  fluid  was  withdrawn 
— making  a  total,  from  the  beginning,  of  85  quarts  !  The  fluid  changed 
character  as  the  tappings  were  repeated  ;  it  became  more  and  more 
mixed  with  blood,  and  at  length  with  pus.  On  one  occasion  a  drachm 
of  the  crystallized  sesquichloride  of  iron,  dissolved  in  six  ounces  of 
water,  was  injected.  This  was  followed  by  severe  symptoms.  At  the 
last,  a  fistulous  passage  into  the  cyst  was  kept  open  by  an  elastic  catheter, 
through  which  the  cyst  was  evacuated  twice  daily,  and  washed  out  with 
warm  water.  Notwithstanding  these  precautions,  the  contents  of  the  cyst 
grew  daily  more  foul,  and  the  patient's  strength  steadily  diminished. 
She  died  after  having  been  under  observation  about  a  year.  On  open- 
ing the  belly  the  cyst  was  found  to  be  the  right  kidney  enormously 
dilated.  The  sac  was  intimately  adherent  to  the  liver ;  and  the  right 
lobe  of  the  latter  was  so  compressed  that  it  was  reduced  to  half  the  size 
of  the  left  lobe.  The  csecum  and  the  end  of  the  ileum  were  fixed  by 
adhesions  to  the  front  of  the  cyst ;  the  rest  of  the  bowels  were  thrust 
into  the  left  hypochondrium.  When  opened,  the  sac  was  found  in  some 
places  thin,  in  others  several  lines  thick  ;  it  was  divided  into  compart- 
ments, of  which  the  parietes  were  traversed  by  broad  membranous  bands 
in  various  directions,  which  divided  the  cavities  into  a  number  of  small 
loculi.  In  these  latter  a  number  of  cysts  with  yellowish  contents  were 
situated.  The  anatomical  cause  of  the  distention  was  not  very  clearly 
made  out ;  but  it  appeared  to  consist  in  a  congenital  obliquity  of  the 
origin  of  the  ureter,  whereby  a  valvular  condition  was  induced,  which 
impeded  the  flow  of  urine.  The  ureter,  after  its  origin  in  the  cyst,  ran 
in  a  half  circle,  downwards  and  backwards,  intimately  adherent  to  the 
cyst  walls  and  compressed  by  them.  A  small  supernumerary  renal 
artery  arose  from  the  aorta  a  few  lines  below  the  principal  branch.  The 
left  kidney  was  enlarged,  but  healthy.  ("Wiener  Med.  Halle,"  1864, 
p.  189.) 

Etiology. — The  anatomical  conditions  which  lay  the  founda- 
tions of  hydronephrotic  distention  of  the  kidney  are  exceed- 
ingly varied.  Out  of  52  cases  which  were  collated  for  the  pur- 
pose of  the  present  article,  there  existed  congenital  malforma- 
tion in  20  cases — affecting  the  kidney,  the  ureter,  or  the  renal 
artery.  In  two  of  these,  a  supernumerary  renal  artery  crossed 
and  compressed  the  ureter  near  its  origin  ;  in  four,  the  ureter 


ETIOLOGY.  485 

was  congeiiitally  imperforate ;  in  three,  the  ureter  entered  obli- 
quely into  the  pelvis  of  the  kidney,  creating  a  valve-like  impedi- 
ment, which  necessarily  increased  as  the  pelvis  expanded.  In  a 
case  of  double  hydronephrosis,  observed  by  myself,  the  details 
of  which  follow,  the  left  ureter  was  greatly  narrowed  at  its 
origin,  and  passed  obliquely  into  the  dilated  pelvis;  while  the 
right  ureter,  which  was  perfectly  normal  in  calibre,  was  com- 
pressed at  its  point  of  exit  from  the  pelvis  by  an  irregular  branch 
of  the  renal  artery.  In  a  case  recorded  by  Dr.  Simpson,  the 
ureters  were  dilated  to  the  thickness  of  the  small  intestine  in 
their  entire  course,  except  at  intervals  where  they  were  folded 
on  themselves,  wdiile  their  vesical  orilices  were  so  contracted 
from  thickening  of  the  vesical  walls,  that  they  barely  admitted 
the  stilette  of  a  blowpipe.  In  a  case  recorded  by  I)r.  Hare  a 
very  curious  deformity  was  found  in  both  ureters,  which  he  thus 
describes  :  "  On  taking  the  mass  (the  dilated  kidney)  in  the 
hands,  and  pressing  very  tirmly,  no  liuid  escaped  by  the  ureter ; 
examining  into  the  cause  of  this,  it  was  found  that  the  ureter,  at 
a  little  distance  from  its  origin,  was  coiled  on  itself — like  a  turn 
and  a  half  of  a  cork-screw  brought  closely  together,  and  that  this 
coil  was  adherent  to  the  lower  part  of  the  dilated  pelvis ;  above 
this  part,  the  ureter  was  slightly  dilated ;  below  it,  not  at  all. 
The  coils  just  mentioned  acted  as  a  valve-like  obstruction  to  the 
course  of  the  urine,  for  on  gently  dissecting  aw^ay,  with  the  point 
of  a  scalpel,  the  tissue  which  held  the  coils  together  and  united 
them  to  the  tumor,  the  retained  fluid  rushed  readily  out  by  the 
end  of  the  ureter  in  a  full  stream.^ 

In  13  out  of  the  20  congenital  cases,  the  hydronephrosis  was 
double — that  is,  it  affected  both  kidneys.  Two  of  these  perished 
stillborn,  one  lived  six  hours,  one  thirty,  and  one  thirty-six 
hours,  while  one  died  twenty  days,  and  another  between  three 
and  four  months  after  birth :  but  Dr.  Hare's  patient  (just  men- 
tioned) survived  to  the  age  of  thirty-eight  years ;  and  the  re- 
maining four  lived  for  periods  varying  from  five  and  a  half  to 
twenty  years.  We  must  assume,  in  these  latter  cases,  that  the 
impediment  to  the  urinary  flow  was  at  first  incomplete  (though 
the  malformation  was  congenital),  and  that  its  eflfects  were  not 
fully  developed  until  a  subsequent  period,  and  then  probably 
with  extreme  slowness. 

In  an  instance  cited  by  Eayer,  the  obstruction  (congenital) 
was  constituted  by  an  imperforate  urethra;^  the  bladder  ureters, 

1  Med.  Times  and  Gaz.,  1858,  i.  234. 

"^  In  a  case  which  occurred  in  the  practice  of  the  late  Dr.  Kitchie,  that  of  a 
male  child,  who  died  thirty-six  hours  after  birth,  an  imperforate  urethra  was  the 
obstructing  cause ;  the  pelvis  of  each  kidney  was  dilated  so  as  to  admit  the  tips  of 
two  fingers.  The  kidneys  themselves  retained  the  lobulated  character  of  the  foetal 
organs. 


486  HYDRONEPHROSIS. 

and  kidneys  were  distended  into  capacious  sacs  (loc.  cit.,  iii. 
504).     Phimosis  also  is  given  as  a  cause  of  hydronephrosis.^ 

Congenital  hydronephrosis  is  often  associated  with  mal- 
formations of  other  organs — imperforate  anus,  harelip,  club- 
foot, etc. 

Of  the  32  cases  in  which  the  obstruction  arose  later  in  life,  it 
was  due,  in  eleven  instances,  to  the  impaction  of  a  calculus  in 
the  ureter ;  and  a  similar  impediment,  although  not  actually 
found,  was  inferred  to  have  existed  at  some  previous  period  in 
three  others.  In  five  cases,  a  narrowing  or  obliteration  of  the 
ureter  existed  near  its  origin  or  its  termination,  produced  pre- 
sumably by  some  past  inflammatory  or  ulcerative  process,  fol- 
lowed by  subsequent  constriction.  In  three  cases  reported  by 
Dr.  Simpson,  the  ureter,  which  was  of  normal,  or  greater  than 
normal  calibre,  was  compressed  immediately  above  the  pelvic 
brim  by  a  thickened  tendinous  band  of  the  peritoneum,  appar- 
ently the  result  of  old  inflammatory  action.  In  six  instances, 
the  ureters  were  compressed  near  their  entrance  into  the  bladder 
by  a  pelvic  tumor — gravid  uterus,  ovarian  cyst,  or  a  cancerous 
growth :  cases  of  this  class  are  no  doubt  much  more  frequent 
than  these  numbers  indicate;  but  they  are  generally  slight  in 
degree,  and  seldom  go  on  to  the  production  of  a  palpable  tumor 
in  the  flank.^ 

In  a  number  of  the  cases  collated,  a  mechanical  cause  for  the 
distention  could  not  be  assigned,  or  such  a  cause  was  only 
obscurely  indicated.  In  some  of  these,  no  doubt,  a  more  care- 
ful inquiry  would  have  solved  the  difiiculty ;  but  still  there  are 
cases  which  must  at  present  be  regarded  as  mechanically  inex- 
plicable. 

In  a  few  cases  hydronephrosis  has  followed  upon  an  injury 
to  the  region  of  the  kidney.^  It  is  probable  that  in  such  cases 
the  injury  has  been  followed  by  inflammation  and  consequent 
formation  of  cicatricial  tissue  which  has  compressed  the  ureter. 

The  two  following  cases  illustrate  in  a  striking  manner  how 
a  congenital  malformation,  which,  at  first,  only  offered  a  slight 
obstruction  to  the  course  of  the  urine,  comes,  step  by  step,  to 

1  See  a  case  reported  by  Dr.  James  in  the  Edinburgh  Medical  Journal, 
1877,  p.  135.  He  believes  that  the  frequent  micturition  was  the  proximate 
cause,  the  contractions  of  the  bladder  preventing  the  iiow  of  urine  through  the 
ureters. 

2  Stadfeldt  found  dilatation  of  the  ureter  common  in  women  dying  in  childbirth, 
even  when  there  was  no  lateral  displacement  of  the  womb.  In  sixteen  post- 
mortem examinations  he  found  such  a  dilatation  nine  times  ;  it  almost  always 
begins  where  the  ureter  crosses  the  common  iliac.  Hydronephrosis  from  this  cause 
(^puerperal)  is  much  more  frequent  on  the  right  than  the  left  side.  Out  of  twelve 
cases,  Stadfeldt  found  it  only  once  on  the  left.  (Monatsschr.  f.  Geburtsk,  1862, 
p.  71.) 

3  See  Croft,  Brit.  Med.  Journ.,  1881,  i.  p.  123 ;  Hicks,  New  York  Med.  Eecord, 
April  17,  1880,  and  Solier,  Lyon  Med.,  No.  45,  1880. 


ILLUSTRATIVE    CASES.  487 

coiiBtitute  a  greater  obstruction,  and  at  length  produces  fatal 

results : 

T.  S.,  'Jit.  20,  came  under  my  care  February  28,  1807.  He  had  been 
subject,  from  the  age  of  two  years,  to  attacks  of  obstruction  of  the 
bowels,  continuing  for  four  or  five  flays,  and  recurring  at  uncertain  in- 
tervals of  a  few  weeks  or  months.  During  these  attacks — which  of  late 
had  been  more  frequent  and  more  severe — the  abdomen  became  swollen 
and  tender,  and  there  were  sickness  and  vomiting.  The  condition  of  the 
urine  had  never  attracted  any  attention. 

When  I  was  called  to  see  him,  he  was  suffering  from  one  of  these 
attacks.  The  bowels  had  not  been  moved  for  five  days;  the  abdomen 
was  distended  and  painful,  and  there  was  frequent  vomiting,  which  was 
not  stercoraceous.     The  urine  was  reported  to  be  exceedingly  scanty. 

On  the  next  day  (March  1)  he  passed  only  four  ounces  of  urine.  The 
characters  of  this  specimen  were  peculiar.  It  was  mixed  with  blood, 
and  its  specific  gravity  was  only  1008;  no  renal  casts  were  found,  but  a 
large  number  of  transitional  epithelial  scales,  such  as  line  the  pelvis  of 
the  kidney.  The  sickness  had  ceased,  but  the  condition  of  the  abdomen 
and  the  constipation  remained  the  same. 

On  examining  the  loins,  it  was  found  that  there  was  distinct  bulging 
in  both  lumbar  regions  ;  the  bulged  portions  had  an  elastic  feel  and  com- 
municated to  the  fingers  an  obscure  sense  of  fluctuation.  Both  loins 
were  dull  on  percussion,  and  the  dulness  reached  forward  to  a  line 
extending  from  the  costal  margins  to  the  anterior  spines  of  the  crista  ilii. 

On  the  next  day — seventh  day  of  intestinal  obstruction — he  passed 
three  ounces  of  urine,  similar  in  character  to  that  before  described.  On 
the  eighth  day,  there  was  total  suppression  of  urine.  On  the  ninth  day, 
copious  discharges  of  urine  took  place,  amounting  in  the  course  of  the 
day  and  night  to  more  than  a  gallon.  The  appearance  of  the  secretion 
was  almost  normal.  It  was  straw-colored  and  clear;  it  contained  no 
albumen,  and  only  microscopical  evidence  of  blood.  It  was  only  un- 
natural in  its  specific  gravity,  which  ranged  in  the  different  specimens 
from  1005  to  1007.  The  bowels  still  continued  without  a  passage  ;  but 
a  sensible  softening  of  the  abdomen  had  taken  place,  and  the  elastic 
swelling  on  the  left  side  was  very  decidedly  diminished  in  size.  On  the 
tenth  day  the  urine  flowed  freely,  and  fully  a  gallon  was  voided  before 
night.  It  had  the  same  characters  as  the  urine  passed  the  previous  day. 
About  midnight,  on  the  tenth  day,  the  intestinal  obstruction  likewise 
gave  way,  and  an  immense  quantity  of  semi-liquid  feces  was  evacuated. 
It  was  now  hoped  that  speedy  recovery  would — at  least  for  a  time — take 
place ;  but  on  the  eleventh  day  the  general  symptoms  were  alarming ; 
no  urine  was  secreted,  the  tongue  and  teeth  became  coated  with  sordes, 
and  the  prostration  was  extreme.  On  the  twelfth  day,  death  took  "place, 
preceded  by  a  fit  of  convulsions,  no  urine  having  been  discharged  for 
sixty  hours. 

Autopsy. — On  opening  the  abdomen,  two  soft,  lobulated  tumors  were 
found,  one  in  each  lumbar  region;  these  were  the  enlarged  and  saccu- 
lated kidneys.  The  left  kidney  was  ten  inches  long  by  about  seven 
broad — the  right  about  a  quarter  less.  To  the  bulging  inner  sides  of 
the  left  kidney,  the  descending  colon  was  firmly  adherent  by  a  broad 


488 


HYDRONEPHROSIS. 


attachment  for  the  space  of  about  three  inches.  It  was  here  that  the 
intestinal  obstruction  lay;  the  bowel  was  contracted  at  this  spot,  and 
tightly  stretched  over  the  distended  kidney  in  such  a  manner  as  to  pre- 
vent the  free  passage  of  feces.  The  kidneys,  ureters,  and  renal  arteries 
were  carefully  dissected  out  with  a  view  of  ascertaining  the  mechanical 
cause  of  the  impediment  to  the  flow  of  the  urine,  which  produced  the 
mischief. 

On  the  left  side  (Fig.  60),  the  renal  artery  was  normal  in  its  distribu- 
tion ;  but  the  ureter  presented  an  anomaly.  At  its  origin  from  the 
dilated  pelvis,  the  ureter  was  exceedingly  narrowed;  its  bore  was  so 


Fig  60. 


Left  kidney,  s)iowing  the  narrowing  at  the  commencement  of  the  ureter  and  the  obliquity  of  its 
entrance  into  the  dilated  pelvis  (about  one-fourth  the  aotvial  size). 

contracted  that  only  a  fine  probe  could  be  passed  along  it.  The  entrance 
of  the  ureter  into  the  pelvis  was  also  oblique,  so  that  a  valve-like  obstruc- 
tion was  thereby  constituted.  The  action  of  this  latter  impediment  was 
clearly  shown  when  the  sacculated  mass,  after  being  separated  from  its 
connection,  was  held  in  the  hand,  and  subjected  to  various  degrees  of 
pressure.  With  moderate  pressure  no  urine  escaped  from  the  cut  end 
of  the  ureter ;  but  when  the  mass  was  strongly  compressed,  the  obliquity 
of  the  origin  of  the  ureter  was  for  the  time  effaced,  and  urine  escaped 
freely.  The  same  thing  doubtless  happened  during  life.  When  the 
distention  of  the  kidney  was  moderate,  the  course  of  the  urine  was 
obstructed  ;  but  when  the  urine  accumulated  and  the  distention  became 
great,  the  obstruction  was  at  length  overcome,  and  the  contents  of  the 
sac  escaped.  The  lower  portion  of  the  left  ureter  was  free  from  obstruc- 
tion, and  of  the  usual  dimensions.     When  this  kidney  was  laid  open,  it 


ILLUSTRATIVE    CASES. 


489 


(with  the  pelvis)  was  seen  to  be  converted  into  one  large  lobulated  sac, 
filled  with  urine  (,?ee  Fig.  61).  The  renal  substance  was  reducer!  to  a 
thin  layer,  varying  from  a  line  to  two  lines  in  thickness,  which  formed 
the  outer  boundary  of  the  sac.  There  were  no  traces  of  the  pyramids. 
The  infundibula  and  calices  were  enormously  dilated,  and  constituted 
the  sacculations  which  gave  the  mass  its  lobular  character. 

The  series  of  changes  which  brought  the  left  kichiey  to  the  state  in 
which  it  was  found,  were  probably  something  as  follows :  The  narrow- 
ing at  the  commencement  of  the  ureter  was  doubtless  congenital,  and 

Pig.  61. 


Tlie  left  kidney  cut  open  (about  one-fourth  the  actual  size). 


constituted,  from  birth,  a  slight  impediment  to  the  free  escape  of  urine, 
and  occasioned  gradually,  in  the  course  of  years,  by  the  distending  force 
of  the  accumulating  urine,  a  dilatation  of  the  pelvis  and  infundibula, 
and  a  progressive  excavation  of  the  kidney.  As  the  pelvis  became 
enlarged  and  distended  with  urine,  it  acquired  a  more  globular  form, 
and  the  orifice  of  the  ureter  was,  in  consequence,  carried  upwards  and 
assumed  an  oblique  direction,  so  that  an  additional  obstacle  to  the  escape 
of  urine  was  thereby  created,  and  one  which  could  only  be  overcome  at 
intervals,  when  the  pressure  from  behind  became  extreme.  The  ad- 
hesion of  the  colon  was  doubtless  an  event  of  later  occurrence,  and 
was  the  consequence  of  irritation  and  inflammation  produced  by  the 
intermittent  pressure  against  it  of  the  distended  kidney  and  pelvis.  It 
is  quite  clear  that,  when  this  adhesion  had  once  taken  place,  temporary 
obstruction  of  the  bowel  would  arise  whenever  the  kidney  became  dis- 
tended with  urine  beyond  a  certain  point;  and  that  when  the  increasing 


490 


HYDRONEPHROSIS. 


accumulation  of  urine  at  length  overcame  —  in  the  manner  already 
explained— the  obstacle  to  its  escape,  the  renal  sac  emptied  itself,  and 
the  intestinal  obstruction  was  also,  for  the  time,  removed.  In  this  way 
may  be  explained  the  recurring  attacks  of  constipation  and  the  manner 
in  which  relief  was  accomplished. 

The  right  kidney  was  in  the  same  sacculated  condition  as  the  left,  but 
the  destruction  had  not  been  carried  to  so  extreme  a  degree.  The 
mechanical  cause  of  the  sacculation  on  this  side  was- essentially  different 
from  that  on  the  left  side.  There  was  no  narrowing  of  any  part  of  the 
right  ureter ;  but  at  its  point  of  exit  from  the  pelvis  it  was  crossed  by 
an  irregular  branch  of  the  renal  artery  (see  Fig.  62).     On  this  (the 


Kight  kiduey  (about  one-fonrth  the  actual  size),  showing  the  abnormal  distribution  of  the  renal  artery. 

right)  side,  two  renal  arteries  arose  from  the  aorta.  The  upper  artery, 
after  giving  off  the  suprarenal  branch,  passed  into  the  upper  part  of  the 
hilus  of  the  kidney.  The  lower  artery  divided  soon  after  its  origin  into 
two  branches,  of  which  one  passed  into  the  hilus  in  the  usual  way ;  but 
the  other  branch  passed  downwards  to  the  lower  part  of  the  kidney,  and, 
in  its  course,  crossed  in  front  of  the  ureter  just  as  the  latter  emerged 
from  the  pelvis  of  the  kidney.  It  is  evident  that  the  slight  constant 
pressure  of  this  branch  produced  a  certain  degree  of  impediment  to  the 
flow  of  urine,  which  in  process  of  time  brought  about  hollowing  and 
sacculation  of  the  kidney. 

The  diagnosis  w^as  made  out  in  this  case  with  accuracy ;  and 
the  proposal  to  puncture  the  renal  sacs  was  only  prevented  from 
being  carried  out  by  the  large  discharges  of  urine  on  the  ninth 
and  tenth  day  of  the  obstruction.  Had  such  punctures  been 
made,  however,  the  relief  obtained  could  only  have  been  tempo- 


ILLUSTRATIVE    CASES.  491 

rary :  the  destruction  of  renal  tissue  liud  gone  too  far  to  leave 
any  hope  of  permanent  cure. 

A  young  man  of  twenty,  otherwise  in  good  health,  had  suffered,  from 
time  to  time,  from  paroxysms  of  pain,  f  )llowed  by  nausea  and  vomiting. 
On  the  -'kl  of  February,  1857,  he  was  seized  with  one  of  these  })aroxysms, 
accompanied  with  obstinate  constipation.  The  vomiting  became  intrac- 
table ;  the  vomited  matters  contained  blood  and  sarcime  ;  and  no  passage 
could  be  obtained  by  the  bowels.  On  examining  the  abdomen,  a  doubt- 
fully fluctuating  swelling  was  detected  in  the  right  flank.  The  symp- 
toms were  attributed  to  an  organic  affection  of  the  liver.  Under  a 
continuance  of  these  symptoms  death  took  place  in  Ave  days. 

At  the  autopsy,  a  bladder-like  tumor  as  large  as  the  fist  was  found  in 
the  right  hypochondrium,  situated  between  the  liver,  the  colon,  and  the 
duodenum  ;  it  was  united  by  adhesions  to  the  two  latter.  The  colon  was 
not  constricted  at  the  adherent  spot ;  but  the  duodenum  was  so  tightly 
stretched  over  the  tumor  that  its  calibre  was  almost  effaced.  The 
stomach  was  greatly  distended,  and  filled  with  a  dark-colored  fluid. 

A  closer  examination  of  the  tumor  revealed  the  following:  It  con- 
sisted of  the  pelvis  of  the  right  kidney,  greatly  distended.  The  right 
renal  artery  was  abnormally  distributed  ;  it  divided  close  to  its  origin 
into  two  branches,  one  of  which  ran  to  the  upper,  and  the  other  to  the 
lower  part  of  the  hilus.  The  lower  branch  crossed  the  ureter  near  its 
origin,  and  exercised  a  certain  compression  upon  it.  The  enlarged  pelvis 
pressed  forward  between  the  two  branches  of  the  renal  artery,  in  such  a 
manner  that  the  origin  of  the  ureter  was  drawn  beyond  the  level  of  the 
lower  renal  artery,  compelling  the  ureter  to  loop  itself  round  this  branch 
in  order  to  reach  the  bladder.  Thereto  was  added  a  third  mechanical 
obstacle,  namely,  the  adhesion  of  the  ureter  in  the  first  part  of  its  course 
to  the  outer  surface  of  the  distended  pelvis,  for  the  space  of  three-quarters 
of  an  inch. 

The  enlarged  pelvis  contained  amraoniacal  urine,  mixed  with  blood 
and  mucus.  The  corresponding  kidney  was  long  and  narrow,  but  other- 
wise healthy,  and  scarcely  atrophic.  The  left  kidney  was  natural. 
(Boogard,  "Arch.  f.  d.  Hollandische  Beitr.  z.  Natur  und  Heilk.,"  Bd.  i. 
p.  196.) 

The  explanation  of  these  appearances  seemed  to  be  this  : 
First,  the  lower  renal  artery  compressed  the  ureter,  and  pre- 
vented the  pelvis  of  the  kidney  from  properly  emptying  itself 
until  a  certain  pressure  was  exerted  on  its  walls  by  the  accumu- 
lated urine.  This  impediment  was  intensified  by  the  curving 
of  the  ureter  round  the  lower  renal  artery.  The  pressure  so 
exercised  probably  excited  inflammation  and  adhesion  of  the 
ureter  to  the  outside  of  the  expanded  pelvis,  and  again  of  the 
latter  to  the  colon  and  duodenum.  The  symptoms  during  life 
were  thus  explained.  The  periodical  attacks  of  nausea  and 
vomiting  depended  on  the  periodical  dilatation  of  the  sac  and 
the  pressure  of  it  on  the  duodenum.  Evacuation  of  the  sac, 
when  the  pressure  of  the  accumulated  urine  reached  a  sufficient 


492  HYDRONEPHROSIS. 

height  to  overcome  the  obstructions,  caused  the  paroxysms  to 
subside.  In  the  last  paroxysm  the  resistance  proved  more 
obstinate;  the  duodenum  became  altogether  occluded — hence 
the  constipation ;  and  the  portal  vessels  became  probably  im- 
plicated— determining  effusion  of  blood  into  the  stomach,  and 
hfematemesis. 

Hydronephrosis  arises  under  such  a  variety  of  anatomical 
conditions,  that  its  general  etiological  relations  oifer,  as  might 
have  been  expected,  little  that  is  characteristic.  No  age  is 
exempt — not  even  foetal  life;  nor  is  any  especially  liable :  the 
two  sexes,  in  the  cases  collated  by  me,  were  found  nearly 
equally  represented — 25  were  males  and  23  females ;  in  4  infants 
the  sex  is  not  mentioned. 

The  Symptoms  of  hydronephrosis  depend  mainly  on  the 
nature  of  its  anatomical  cause  and  on  the  size  of  the  sac.  If 
the  sac  be  small  and  the  opposite  kidney  sound,  symptoms 
may  be  altogether  wanting;  old  age  may  be  reached  without 
suspicion  that  one  of  the  kidneys  has  been  changed  into  a 
membranous  sac,  and  the  anomaly  may  be  first  discovered  at 
the  autopsy. 

Generally,  however,  the  distention  goes  on  to  the  formation 
of  a  palpable  tumor  in  the  abdomen ;  and  sometimes,  as  we 
have  seen,  this  tumor  attains  an  enormous  size.  Setting  aside 
the  cases  which  perished  stillborn,  or  within  a  few  weeks  of 
birth,  there  existed  among  the  42  remaining  instances  25  in 
which  abdominal  intumescence  was  detected  during  life ;  in 
19  of  these  the  tumor  was  confined  to  one  side,  in  6  a  double 
tumor  existed. 

In  its  topographical  character  a  hydronephrotic  tumor  pre- 
sents the  general  physical  signs  of  renal  tumor.  The  swelling 
is  situated  in  the  flank;  it  reaches  backwards  in  the  lumbar 
region  to  the  spine,  upwards  into  the  hypochondrium,  down- 
wards into  the  iliac  region,  and  forwards  to  the  umbilicus — en- 
croaching on  these  regions  variously  according  to  its  magnitude. 
The  colon  is  usually  in  front  of  it ;  and  the  small  intestines  are 
thrust  into  the  opposite  side  of  the  abdomen.  Of  the  several 
displacements  of  the  organs  on  either  side  I  need  not  add  any- 
thing to  what  is  detailed  in  the  chapter  on  cancer  of  the  kidney, 
where  the  general  characters  of  renal  tumor  are  fully  described. 
The  special  characteristics  of  hydronephrosis  are  its  soft  undu- 
lating feel ;  an  outline,  which  is  sometimes  distinctly  lobulated; 
and  the  evidence  of  fluctuation.  There  is  one  peculiarity  which 
is  pathognomonic  when  present,  namely,  the  sudden  diminution 
or  disappearance  of  the  swelling  coincidently  with  the  sudden 
discharge  of  a  large  quantity  of  urine.  This  sign  is  not  always 
available;  but  it  is  sufficiently  frequently  met  with  to  give  it  an 


SYMP'J'OMS.  493 

important  diagnostic  value.  It  occurred  in  9  out  olthe  25  cases 
in  which  the  existence  of  a  tumor  was  clinically  ascertained. 

In  Dr.  Hare's  case  of  double  hydronephrosis,  already  alluded 
to,  subsidence  of  the  tumor  on  the  right  side  took  place,  from 
this  cause,  on  several  occasions  the  tumor  each  time  reappear- 
ing:  that  on  the  left  side  also  disappeared  but  did  not  return. 
Such  cases  of  "  intermittent  hydronephrosis "  are  very  rare. 
Another  case  of  the  kind  reported  by  Mr.  Thompson  will  be 
found  below  (see  page  497).  Mr.  Henry  Morris  has  collected 
six  cases  in  which  the  affection  was  intermittent.  To  these  he 
has  added  one  case  observed  by  himself,  where  the  intermittent 
hydronephrosis  of  the  right  side  was  due  to  a  villous  growth  of 
the  bladder,  obstructing  the  orifice  of  the  ureter,  but  where  the 
disappearances  of  the  tumor  were  not  associated  with  any  ab- 
normal excretion  of  fluid. 

The  tumor  is  usually  quite  painless,  and  unaccompanied  by 
any  inconvenience  except  from  its  bulk.  Occasionally,  how- 
ever, tenderness  exists  over  it ;  and  the  action  of  the  bowels  is 
irregular.  When  the  dilatation  arises  from  the  impaction  of  a 
€alculus,  symptoms  of  nephritic  colic  occur  at  the  time  when  the 
impaction  takes  place ;  or  from  time  to  time  thereafter,  if,  as  is 
most  usual,  some  quantity  of  urine  still  continues  to  trickle  past 
the  calculus.  Similar  paroxysms  are  recorded  in  two  instances 
where  no  calculus  existed. 

The  state  of  the  urine  usually  furnishes  no  information :  in 
the  great  majority  of  cases  it  is  natural;  sometimes,  however, 
it  contains  a  little  pus ;  but  never  in  quantity.  During  the 
attacks  of  nephritic  colic  it  may  contain  blood;  and  be  discharged 
with  great  pain,  retraction  of  the  testicle,  vomiting,  etc.  The 
history  of  these  attacks  sometimes  yields  an  important  clew  to 
the  nature  of  the  case.  When  both  kidneys  are  aifected,  symp- 
toms indicating  defective  elimination  of  urine  (ursemia)  neces- 
sarily show  themselves  at  length.  A  hydronephrosis  implicating 
one  kidney  only  may,  as  we  have  seen,  cause  little  or  no  incon- 
venience for  many  years,  even  though  its  bulk  be  considerable. 
The  opposite  kidney  performs  a  double  duty  and  becomes  corre- 
spondingly enlarged.  An  individual  in  this  condition,  however, 
leads  an  existence  of  considerable  peril :  for  if  anything  happen 
to  impede  the  function  of  the  single  kidney  on  which  life  de- 
pends, dangerous  symptoms  necessarily  arise.  Rayer  supplies 
the  following  instructive  example  : 

M.  v.,  set.  64,  had  experienced,  at  the  age  of  22,  pain  in  the  right 
renal  region,  shooting  obliquely  towards  the  bladder  in  the  direction  of 
the  ureter.  This  pain  proved  obstinate,  and  increased  more  and  more ; 
the  urine  was  occasionally  bloody,  and  sometimes  of  a  dark  color ;  the 
patient  became  pale  and  thin.     Little  by  little  the  urine  ceased  to  con- 


494  HYDEONEPHROSIS. 

tain  blood,  and  reassumed  its  normal  characters ;  the  general  condition 
was  perfectly  restored ;  and  for  a  long  series  of  years  M.  V.  enjoyed 
blooming  health. 

About  the  year  1820,  M.  V.  began  to  grow  stout ;  the  belly  became 
remarkably  large  ;  and  latterly  his  great  size  considerably  impeded  pro- 
gression. 

On  the  18th  of  September,  1834,  M.  V.  experienced  an  uneasiness  in 
the  abdomen  which  constrained  him  to  keep  his  bed ;  pains  were  felt  all 
over  the  abdomen,  but  especially  towards  the  region  of  the  left  kidney. 
This  region  was  tender  on  pressure ;  the  patient  passed  no  urine ;  and 
the  bladder  was  not  distended.  During  ten  days  M.  V.  had  no  desire 
to  void  urine,  and  at  the  end  of  this  period  he  only  passed  two  glasses 
of  a  citrine  color.  On  examining  the  abdomen  a  voluminous  tumor 
was  detected,  extending  obliquely  from  the  right  hypochondrium  to  the 
left  iliac  fossa.  Obscure  fluctuation  was  felt  in  the  tumor,  which  was 
considered  to  be  formed  by  the  distended  right  kidney  (this  was  con- 
firmed at  the  autopsy).  The  condition  grew  more  and  more  serious  as 
the  suppression  of  urine  continued — the  tongue  became  covered  with  a 
slimy  coating ;  the  features  altered  ;  the  nights  were  sleepless ;  the  pulse 
failed ;  hiccough  supervened ;  and  the  patient  expired  on  the  loth  of 
October,  1834. 

On  opening  the  body  the  right  kidney  was  found  prodigiously  dis- 
tended, and  converted  into  a  pouch  filled  with  7  lbs.  11  ozs.  of  a  viscid 
fluid ;  the  tumor  was  16  inches  long  from  above  downwards,  and  7J 
inches  broad.  The  ureter  was  dilated  at  its  origin,  but  soon  underwent 
a  sudden  constriction  ;  in  this  strangulated  part  a  little  calculus  could 
be  felt  which  had  completely  obstructed  the  duct.  Below  this  obstacle, 
the  ureter  resumed  its  ordinary  dimensions.  The  left  kidney  was  con- 
siderably tumefied  and  reddened.  The  pelvis  was  notably  dilated  and 
covered  with  vascular  ramifications ;  the  left  ureter,  like  the  right,  con- 
tained a  small  calculus  lodged  five  inches  below  the  pelvis.  The  bladder 
and  other  abdominal  organs  were  healthy.  The  state  of  the  right  kid- 
ney explained  perfectly  the  former  ailments  of  M.  V.,  and  death  was 
the  consequence  of  the  disabling  of  the  solitary  kidney  on  which  his  life 
had  so  long  depended.     ("  Mai.  des  Reins,"  t.  iii.  p.  490.) 

Terminations. — Hydronephrosis  may  terminate  in  various 
ways.  The  obstacle  may  be  dislodged,  and  the  contents  of  the 
sac  discharged,  without  subsequent  reaccumulation.  If,  in  such 
a  case,  a  portion  of  the  renal  tissue  be  preserved,  the  organ  will 
be  enabled,  in  part,  to  resume  its  function.  If  the  distention 
has  been  long  established,  and  the  secreting  tissue  extensively 
or  totally  absorbed,  the  organ  after  evacuation  of  the  fluid 
shrivels  up  into  an  empty  sac.  These  may  be  regarded  as  the 
most  favorable  modes  of  termination. 

I  find  that  out  of  40  fatal  cases,  which  supply  intbrmation 
as  to  the  cause  of  death,  16  perished  from  some  other  disease. 
jSTearly  all  of  these  were  slight,  unilateral  cases,  which  were 
latent  during  life.  Five  cases  of  double  hydronephrosis  per- 
ished stillborn  or  soon  after  birth  from  abeyance  of  the  urinary 


DIAGNOSIS.  495 

function.  In  19  cuscs  death  took  place  at  a  later  age  us  a  direct 
or  indirect  consequence  of  the  renal  distention.  Of  these  19, 
one  died  wearied  out  with  the  bulk  of  the  tumor  and  dysenteric 
diarrhcjoa  caused  thereby.  Mr.  Glass's  patient  died  from  jjressure 
of  the  vast  sac  on  the  respiratory  organs.  Five  cases,  in  which 
double  hydronephrosis  was  established  gradually,  died  from  pro- 
gressive abolition  of  the  renal  function — four  of  them  with  dis- 
tinct ursemic  symptoms,  one  of  whom  (see -p.  487)  had  also  intes- 
tinal obstruction  due  to  constriction  of  the  descending  colon, 
which  had  become  lirmly  adherent  to  the  ?iydronephrotic  kid- 
ney. Two  more,  with  single  hydronephrosis,  died  from  suj)- 
pression  of  urine  through  impaction  of  a  calculus  in  the  opposite 
ureter.  In  four  cases,  repeated  tapping  was  followed  by  suppu- 
ration of  the  sac  and  exhausting  hectic :  in  one,  Dr.  Hiller's 
case,  the  patient  succumbed  to  acute  tuberculosis.  In  another 
case,  the  second  tapping  was  succeeded  by  fatal  peritonitis. 
Pressure  of  the  tumor  on  the  adherent  duodenum,  and  conse- 
quent intestinal  obstruction,  caused  death  in  one  instance  (p. 
491).  It  is  remarkable  that  only  in  one  solitary  instance  (to  be 
presently  cited)  was  death  caused  by  spontaneous  rupture  of  the 
sac. 

Diagnosis. — -The  diagnosis  of  hydronephrosis  is  certain  and 
easy  only  when  subsidence  of  the  tumor  occurs  simultaneously 
with  a  sudden  excessive  discharge  of  urine,  or  when  trustworthy 
history  of  such  an  occurrence  can  be  obtained.  When  this 
symptom  is  absent,  the  recognition  of  the  disease  depends  on  the 
ascertainment  of  the  existence  of  a  fluctuating  renal  tumor,  and 
the  absence  of  the  signs  of  suppuration. 

Tlydronephrotic  tumors  have  most  frequently  been  confounded 
with  ovarian  cysts,^  ascites,  and  hydatid  cysts.  From  an  ovarian 
cyst,  hydronephrosis  is  distinguished  by  the  presence  of  the 
colon  in  front  of  the  swelling,  and  by  the  absence  of  a  boAvel 
sound  on  percussion  in  the  corresponding  lumbar  region. 
Ascites  is  distinguished,  when  the  hydronephrosis  is  single,  by 
the  existence  of  dulness  in  both  flanks  :  but  when  the  renal 
tumor  is  double,  and  both  flanks  are  consequently  dull  as  in 
ascites,  the  latter  condition  is  recognized  by  the  change  of  level 
assumed  by  the  fluid  when  the  posture  of  the  patient  is  altered — 
dulness  from  dilated  kidneys  being  flxed  in  its  limits  however  the 
position  of  the  patient  may  be  changed.  A  hydatid  cyst  is 
generally  identified  by  the  escape  of  hydatid  vesicles  with  the 

^  An  interesting  case  of  an  attempted  removal  of  an  immense  liydronephrotic 
kidney,  mistaken  for  an  ovarian  cyst, — followed  by  the  death  of  the  patient,  is 
reported  in  the  Archiv.  f.  klin.  Chir.,  1865.  The  cause  of  the  hydronephrosis 
was  a  valvular  flap  of  membrane  at  the  origin  of  the  ureter,  which  prevented 
the  free  escape  of  urine.  Another  case,  in  which  the  patient  died  on  the  twentj^- 
second  day  after  the  operation,  is  reported  in  the  Berl.  klin.  Wochenschr. ,  vi.  23, 
1869. 


496  HYDRONEPHROSIS. 

urine,  and  sometimes  by  the  presence  of  a  hydatid  fremitus.  In 
the  absence  of  these  symptoms  it  may  be  quite  impossible  to 
establish  the  differential  diagnosis  of  these  two  conditions  by 
physical  signs,  and  inferences  must  be  drawn  from  the  history. 
It  may  be  of  use  to  remember,  that  while  hydronephrosis  is  not 
unfrequently  double,  a  hydatid  cyst  is  scarcely  ever  so. 

Pyonephrosis  is  distinguished  by  the  purulent  character  of  the 
urine — actual  or  historical — also  by  the  existence  of  more  severe 
constitutional  symptoms,  and  especially  of  hectic  and  recurrent 
rigors.  Circumscribed  abscess  of  the  kidney,  and  perinephritic 
abscess,  are  distinguished  by  their  more  acute  course,  the  pres- 
ence of  pain  and  the  signs  of  suppuration. 

The  Prognosis,  although  necessarily  grave,  is  less  serious  than 
in  other  kinds  of  renal  tumor.  When  the  affection  is  unilateral, 
not  onl}^  may  life  be  indeffnitely  prolonged,  but  there  is  always 
a  chance  that  spontaneous  evacuation  of  the  sac  may  take  place, 
or  that  the  cyst  ma}^  be  punctured  with  success.  If  the  opposite 
(hitherto  sound)  kidney  show  symptoms  of  deranged  function, 
the  gravity  of  the  prognosis  is  immensely  increased.  When 
both  kidneys  are  affected  the  issue  is  unavoidably  fatal  at  length ; 
but  many  years  may  elapse  before  the  atrophy  of  the  secreting 
tissue,  or  the  completeness  of  the  obstruction,  reaches  a  degree 
incompatible  with  life. 

Treatment. — If  the  disease  be  unilateral,  and  inferred  to 
depend  on  the  impaction  of  a  calculus  in  the  ureter,  precautions 
should  betaken  against  a  similar  occurrence  taking  place  on  the 
opposite  side.  The  patient  should  be  directed  to  keep  the  urine 
adequately  diluted  by  systematic  potation,  especially  on  going  to 
bed,  and  to  avoid  a  too  highly  animalized  diet. 

In  the  absence  of  this  indication  an  attempt  may  be  made  to 
overcome  the  obstacle,  or,  if  that  be  impossible,  to  facilitate  the 
passage  of  the  urine  past  it.  To  this  end,  the  tumor  should  be 
carefully  manipulated  or  shampooed,  from  time  to  time.  As  the 
swelling  is  usually  painless,  this  can  be  accomplished  without 
difficulty.  In  a  little  girl  of  eight,  who  came  under  my  care  in 
the  Manchester  Infirmary,  this  treatment  seemed  to  be  followed 
by  success.  She  had  a  soft,  obscurely  fluctuating  tumor  on  the 
left  side  of  tVie  abdomen,  about  the  size  of  a  child's  head,  which 
was  considered  to  be  hydronephrosis.  This  was  diligently 
manipulated  in  every  direction,  with  the  aid  of  a  lubricating 
ointment,  on  alternate  mornings.  After  the  third  manipulation, 
she  suddenly  passed  a  large  quantity  of  urine,  and  the  tumor 
forthwith  subsided,  and  did  not  again  return  so  long  as  the 
patient  continued  under  observation. 

If  evacuation  cannot  be  obtained  in  this  manner,  further 
interference  is  in  my  opinion  not  justified  unless  the  expansion 
of  the  sac  be  such  that  its  pressure  threatens  serious  mischief. 


TREATMENT.  497 

Under  these  circumstances  tappint^  may  l^e  rcBortod  to.  TJjc 
following  case,  related  by  Mr.  Thompson,  of  iS^ottingliam, 
furnishes  an  example  of  the  successful  adoption  of  this  plan  ; 
and  the  reasons  set  forth  by  the  writer  for  the  selection  of  the 
spot  chosen  for  puncture  seem  to  deserve  attention.  This  case 
is  likewise  the  solitary  instance  I  have  discovered,  in  which 
death  was  caused  by  bursting  of  the  sac  into  the  peritoneum. 

The  patient  came  under  Mr.  Thompson's  observation  in  May,  1851. 
He  was  at  that  time  suffering  from  great  pain  in  the  region  of  the  left 
kidney.  There  were  considerable  enlargement  and  tenderness  on  pres- 
sure extending  over  the  left  hypochondriac,  lumbar,  and  iliac  regions. 
Dulness  on  percussion  also  existed  in  these  regions.  Symptoms  of 
nephritic  colic  had  existed  for  a  considerable  period.  Similar  symp- 
toms had  been  observed  on  a  previous  occasion,  which  were  suddenly 
relieved  after  passing,  all  at  one  time,  more  than  a  chamber-pot  full  of 
water,  of  the  color  of  port  wine.  On  the  present  occasion,  a  similar 
event  took  place ;  in  about  a  week  the  sac  had  entirely  emptied  itself 
through  the  ureter  and  bladder.  The  symptoms  disappeared,  and  the 
patient  apparently  soon  recovered.  In  November  he  began  again  to 
suffer  from  the  same  symptoms,  which  increased  up  to  January  27, 
1852.  At  this  time  the  side  was  greatly  enlarged  and  tender.  There 
was  an  obscure  sense  of  fluctuation,  and  the  dulness  extended  to  the 
right  as  far  as  the  linea  alba;  backwards  to  the  spine;  downwards  to 
the  lowest  part  of  the  iliac  fossa.  The  organs  in  the  chest  were  dis- 
placed upwards.  The  patient's  sufferings  were  now  so  great  that  it  was 
determined  to  draw  off  the  fluid  with  the  trocar.  There  was  no  doubt 
that  the  sac  containing  the  fluid  was  a  dilated  kidney,  or  a  cyst  con- 
nected with  the  pelvis  of  that  organ ;  and  in  either  case  Mr.  Thompson 
was  disposed  to  select  the  interval  between  the  last  two  (floating)  ribs 
near  their  anterior  extremities  at  which  to  introduce  the  trocar.  Mr. 
T.  fixed  on  this  spot  for  the  following  reasons  : 

1.  Supposing  the  fluid  to  be  contained  in  a  sac  having  communica- 
tion with- the  pelvis  of  the  kidney,  the  kidney  would  lie  behind  the  sac, 
partly  upon  the  last  two  ribs,  and  partly  upon  the  quadratus  lumborum 
muscle,  its  normal  situation  upon  this  side ;  and  if  the  instrument  were 
introduced  at  the  place  indicated,  and  its  point  directed  a  little  forward, 
it  would  penetrate  the  sac  without  any  risk  of  wounding  the  kidney. 

2.  If  the  sac  consisted  of  a  dilated  kidney,  the  point  selected  would 
still  be  the  best,  as  it  would  be  near  the  part  at  which  the  organ  began 
to  dilate. 

3.  It  would  be  behind  the  peritoneum,  and  therefore  there  would  be 
less  risk  of  wounding  that  membrane. 

4.  If  the  patient  had  been  tapped  in  front,  the  trocar  must  have 
passed  through  the  peritoneum  twice :  first,  that  portion  lining  the 
abdominal  muscles,  and,  second,  that  in  front  of  the  sac;  and,  sup- 
posing no  adhesion  to  have  taken  place  between  these  two  parts,  when 
the  instrument  was  withdrawn,  some  of  the  contents  of  the  sac  might 
have  escaped  into  the  cavity  of  the  peritoneum  and  given  rise  to  inflam- 
mation.    Besides,  there  would  have  been  more  danger  of  wounding  some 

32 


498  HYDRONEPHROSIS. 

of  the  bowels,  should  any  portion  have  become  adherent  by  inflanamation 
between  the  walls  of  the  abdomen  and  the  sac. 

The  operation  was  therefore  performed  between  the  last  two  ribs  near 
their  extrefaities.  An  incision  was  made  through  the  integuments  and 
muscles;  a  small  exploring  trocar  was  then  introduced;  and  as  there 
was  evidence  of  the  existence  of  fluid,  a  larger  instrument  was  inserted, 
with  its  point  directed  slightly  forward,  and  eight  quarts  of  dark-colored 
fluid  were  drawn  off".  It  was  a  singular  fact  (which  was  explained  on 
examination  of  the  specimen  after  death),  that  soon  after  this  fluid  was 
removed,  the  further  contents  of  the  sac  flowed  in  the  natural  direction 
along  the  ureter. 

The  patient  soon  recovered ;  but  it  was  necessary  to  repeat  the  opera- 
tion in  December,  1852,  when  3^  quarts  of  fluid  were  extracted ;  soon 
after  which,  as  before,  the  sac  emptied  itself  through  the  natural  pas- 
sages. 

The  patient  soon  got  well,  and  did  not  require  the  operation  again 
until  near  eight  years  afterwards  (March,  1860).  At  this  time  seven 
quarts  were  taken  away;  not  long  after  which  the  fluid  again  found  its 
way  along  the  natural  passages,  and  the  patient  again  made  a  quick 
recovery,  and  remained  well  until  September,  1861.  When  then  seen 
by  Mr.  T.,  he  was  suffering  from  his  old  symptoms.  On  the  5th  ot 
October  he  was  suddenly  seized  with  pain  in  the  abdomen,  with  difficulty 
of  micturition,  cold  sweats,  rapid  pulse,  and  an  anxious  countenance.  He 
went  on  pretty  well  until  the  10th  of  October,  when  he  suddenly  became 
worse  and  died. 

The  post-mortem  examination  revealed  intense  peritonitis.  Three  pints 
of  dark-colored  fluid  (resembling  that  found  in  the  sac)  were  removed 
from  the  right  hypochondriac  and  epigastric  regions.  The  sac  proved 
to  be  the  distended  left  kidney — it  contained  four  pints  of  fluid  ;  a  hole 
was  discovered  toward  the  left  side  anteriorly,  where  the  rupture  had 
taken  place.  The  descending  colon  lay  before  and  toward  the  left  side 
of  the  sac;  the  ureter  entered  the  cavity  of  the  sac  obliquely  through 
the  wall  of  the  cyst.  This  obliquity  of  the  entrance  of  the  ureter  offered 
a  probable  explanation  of  the  closure  of  that  tube  when  the  sac  was  full, 
and  the  open  state  of  it  when  the  sac  was  empty.  The  rupture  doubt- 
less took  place  on  the  5th  of  October, when  the  peritonitis  began;  and  in 
all  probability  there  was  some  escape  of  fluid,  but  not  much  at  that 
time;  a  further  and  larger  escape  took  place  on  the  10th,  after  which 
the  patient  rapidly  sank.  There  was  no  stone  found  in  the  bladder,  nor 
any  obstruction  in  the  lower  course  of  the  ureter.  (J.  Thompson,  "  Path. 
Trans.,"  vol.  xiii.) 

The  early  history  of  the  case  caused  Mr.  Thompson  to  sur- 
mise that  the  patient  had  formerly  voided  urinary  calculi;  but 
none  were  ever  found.  It  is  quite  as  possible  that  the  obliquity 
of  the  entrance  of  the  ureter  into  the  pelvis  of  the  kidney  v^as 
a  congenital  malformation,  and  that  this  constituted  the  real 
cause  of  the  hydronephrosis. 

Dr.  Hiller  relates  another  case  of  congenital  hydronephrosis 
repeatedly  tapped,  in  front,  w^ith  temporary  success : 


ILLUSTKATI  Vi<:    CASKH.  499 

The  patient  was  born  with  great  enlargement  of  the  abdomen,  simu- 
lating ascites,  for  which  it  was  mistaken  till  he  was  nearly  four  years 
old.  It  was  then  ascertained  to  be  an  enormous  cyst  springing  from  the 
right  lumbar  region.  From  its  great  size  it  caused  dilficulty  of  breath- 
ing and  prevented  his  walking.  The  cyst  was  tapped  in  front,  and  102 
fluid-ounces  of  clear  non-albuminous  fluid  were  drawn  off,  iiaving  all  the 
characters  of  dilute  urine.  The  fluid  rapidly  re-collected,  and  on  a 
second  tapping  was  found  to  be  albuminous  and  purulent,  but  still  to 
contain  a  considerable  quantity  of  urea.  Attempts  were  made  to  estab- 
lish a  permanent  fistula  anteriorly,  and  then  posteriorly;  but  on  each 
occasion  the  fluid  after  a  time  ceased  to  flow.  Much  irritation  and 
depression  followed  the  several  tappings,  so  that  the  patient's  life  seemed 
to  be  endangered.  After  one  of  the  operations  a  quantity  of  fluid  was 
passed  from  the  bladder  exactly  similar  to  that  from  the  cyst,  and  quite 
unlike  what  was  usually  passed  from  the  urethra;  a  temporary  com- 
munication thus  obviously  being  established  between  the  cyst  and  the 
bladder.  When  the  case  was  reported,  the  patient  had  been  left  without 
operation  for  some  months,  and  had  regained  his  strength ;  but  the  cyst 
remained,  varying  from  time  to  time  in  size,  and  the  urine  was  often 
purulent  and  fetid.  It  was  presumed  that  there  was  some  congenital 
malformation  of  the  right  ureter  which  rendered  it  liable  to  occlusion, 
but  admitted,  under  some  circumstances,  of  the  passage  of  fluid.  ("  Brit, 
Med.  Journ.,"  April  8,  1865.) 

The  follow^ing  is  an  abstract  of  the  completion  of  this  case  : 

The  patient  remained  under  occasional  observation  between  the  above 
date  and  July  16,  1868,  when  he  was  admitted  into  hospital  under  Dr. 
Hillier,  suffering  from  headache  and  feverishness.  During  this  interval 
he  had  been  once  tapped,  and  a  quantity  of  urine-like  fluid  was  drawn 
off.  Acute  tuberculosis  manifested  itself,  the  patient  gradually  sank, 
and  died  on  the  5th  of  August.  On  post-mortem  examination,  the  great 
distention  of  the  abdomen  was  found  to  be  due  to  the  presence  of  a  large 
cyst,  which  filled  the  greater  part  of  the  cavity.  The  cyst,  which  meas- 
ured twenty-seven  inches  in  circumference  over  the  long  diameter,  and 
twenty-four  over  the  short  one,  appeared  to  take  the  place  of  the  right 
kidney — the  suprarenal  capsule,  apparently  normal,  being  attached  to 
it.  The  ureter  proceeded  from  the  lower  part  of  the  cyst,  to  which  it 
was  attached  for  about  an  inch  ;  the  orifice  of  the  ureter  at  its  vesical 
extremity  was  found  smaller  than  usual.  When  a  small  dressing-probe, 
which  was  with  difficulty  passed  up  the  ureter,  reached  within  two 
inches  of  the  cyst,  and  was  then  withdrawn,  fluid  could  be  squeezed  out 
of  the  cyst  through  the  ureter  into  the  bladder  guUatim.  This  could 
not  be  done  previous  to  the  passage  of  the  probe.  The  cyst  contained 
83  ounces  of  clear  fluid  of  a  pale  lemon  color  and  urinous  smell,  specific 
gravity  1002,  very  slightly  acid,  with  the  faintest  trace  of  albumen,  and 
presenting  under  the  microscope  a  few  broken-down  cells  of  large  size. 

The  left  ureter  was  about  an  inch  in  diameter  at  its  upper  two-thirds, 
natural  in  size  below,  but  contained  calculous  matter,  forming  an  obstruc- 
tion to  the  flow  of  fluid,  which  could,  however,  be  easily  overcome.  The 
pelvis  of  the  left  kidney  was  dilated   sufficiently  to  contain  a  small 


500  HYDRONEPHROSIS. 

pigeon's  egg,  and  contained  a  little  calculous  matter,  found  on  examina- 
tion to  consist  of  uric  acid.  Tubercles  were  found  in  the  brain,  lungs, 
liver,  and  spleen.     ("  Med.-Chir.  Trans.,"  lii.,  1869.) 

When  the  tumor  is  on  the  left  side,  as  in  Mr.  Thompson's 
case,  mentioned  above,  the  best  point  for  tapping,  is  just  ante- 
rior to  the  last  intercostal  space.  Mr.  Morris  has  tested  this  in 
the  post-mortem  room  and  has  found  that  in  no  instance  was  the 
spleen  injured.  On  the  right  side,  however,  such  a  puncture 
would  pierce  the  liver,  and  Mr.  Morris  here  recommends  a  spot 
"  half  way  between  the  last  rib  and  the  crest  of  the  ilium,  be- 
tween two  inches  and  two  inches  and  a  half  behind  the  anterior 
superior  spine  of  the  ilium." 

In  recent  years  the  whole  mass  has  been  successfully  removed 
by  abdominal  incision  {see  cases  by  Dr.  Savage  and  Mr.  Know- 
seley  Thornton  in  the  "  Lancet,"  1880,  vol.  I.). 


CHAPTER   IX. 

CYSTS  AND  CYSTIC  DEGENERATION  OF  THE  KIDNEYS. 

Cysts  are  found  in  the  kidneys  under  four  practically  different 
circumstances,  namely  :  1.  Scattered  cysts  in  kidneys  otherwise 
healthy.  2.  Disseminated  cysts  in  the  atrophic  form  of  Bright's 
disease.  3.  Congenital  cystic  degeneration.  4.  General  cystic 
degeneration  in  adults. 

1.  Scattered  Cysts  in  Kidneys  Otherwise  Healthy. — It  is 
not  uncommon  to  find  on  the  surface  of  healthy  kidneys  one  or 
more  cysts,  with  delicate  walls,  varying  in  size  from  a  pea  to  a 
marble  or  walnut.  One  or  more  of  similar  appearances  may 
also  be  found  in  the  interior  of  the  gland,  chiefly  in  the  cortical 
substance.  Such  cysts  are  filled  with  a  yellowish  albuminous 
fluid — usually  difliuent,  sometimes  gelatinous, — containing  phos- 
phates and  carbonates,  sometimes  a  large  quantity  of  choles- 
terine,  and  very  rarely  urea  and  uric  acid. 

Cysts  of  these  dimensions  do  not  produce  any  symptoms 
during  life  ;  and  their  efiects  on  the  functions  of  the  gland  are 
insignificant.  Sometimes,  however,  cysts  of  this  class  attain  a 
monstrous  size,  and  form  a  tumor  recognizable  during  life. 
Mr.  Csesar  Hawkins  gives  an  account  of  a  remarkable  case  in 
which  the  right  kidney  of  a  boy,  six  years  of  age,  had  an  enor- 
mous cyst  attached  to  it.  The  cyst  filled  the  entire  right  side  of 
the  abdomen  from  the  false  ribs  to  Poupart's  ligament.  The  at- 
tached kidney  was  healthy  in  its  structure,  and  the  ureter  free. 
In  the  wall  of  the  cyst,  separated  by  a  distance  of  five  inches 
from  the  kidney,  there  was  inserted  a  small  mass  about  the  size 
of  a  walnut,  which  projected  into  the  cavity  of  the  cyst.  This 
body  proved  to  be  a  third  kidney,  consisting  of  a  single  lobule, 
with  the  cortical  and  tubular  part  perfect;  and  having  a  single 
mammillary  process  and  calyx;  but  no  excretory  duct  could  be 
traced.  The  urine  had  been  natural.  The  cyst  was  punctured 
during  life ;  and  about  five  pints  of  fluid  were  found  in  it  'after 
death.  The  fluid  contained  neither  albumen  nor  any  of  the 
special  urinary  ingredients. 

Dr.  Hare  ("Path.  Soc.  Trans.,"  vol.  iv.  p.  199)  describes  a  very 
similar  cyst  taken  from  a  man  aged  sixty-two.  A  "tumor  was 
detected  during  life  on  the  right  side,  stretching  from  the  ribs 
to  the  pubes.  After  death,  a  large  cj^st  was  found  connected 
with  the  right  kidney.     The  lower  half  of  the  gland  was  partly 


502  CYSTIC    DEGENEKATION    OF    THE    KIDNEYS. 

spread  out  over  a  portion  of  the  tumor,  and  partly  absorbed. 
The  upper  half  was  healthy;  nor  did  it  (nor  the  opposite  kid- 
ney) contain  any  other  cyst,  with  the  exception  of  one,  about  as 
large  as  a  hempseed.  The  large  cyst  contained  an  almost  trans- 
parent, pale,  yellowish-green  fluid,  quite  limpid  and  diffluent 
when  the  cyst  was  first  opened :  but  after  the  fluid  had  been  ex- 
posed a  few  minutes  to  the  air  it  set  into  a  tremulous  jelly. 

In  neither  of  these  two  cases  was  the  pelvis  of  the  kidney 
nor  ureter  dilated.  In  both  cases  the  disease  was  doubtfully 
traced  to  external  violence. 

2.  Disseminated  Cysts  in  the  Atkophic  Form  of  Bright's 
Kidney. — These  have  already  been  noticed  in  connection  with 
Bright's  disease  (see  p.  401.) 

3.  Congenital  Cystic  Degeneration  of  the  Kidneys. — A 
considerable  number  of  these  curious  cases  have  been  published, 
and  most  of  them  have  been  collated  by  Yirchow  in  two  elabor- 
ate papers  (Gesammelte  Abhandlungen,  pp.  837  and  864). 

Kidneys  in  this  condition  present  an  enormous  proportionate 
bulk,  being  as  large  as,  or  larger  than,  the  kidneys  of  adults. 
In  all  but  two  cases  both  kidneys  were  affected.  In  several 
instances  embryotomy  was  required  to  effect  delivery,  on 
account  of  the  immense  size  of  the  abdomen.  The  foetus 
(generally  expelled  prematurely)  is  necessarily  stillborn  if  both 
sides  are  afiected,  on  account  of  the  pushing  up  of  the  dia- 
phragm, and  the  mechanical  obstacle  thus  created  to  the  expan- 
sion of  the  lungs. 

Dr.  Lever  ("  Path.  Soc.  Trans.,"  1848-9,  p.  74)  has  recorded  the 
following  typical  example.  The  foetus  was  one  of  eight  months. 
It  was  clubfooted  and  clubhanded ;  it  had  six  fingers  on  the 
left  hand  and  as  many  toes  on  each  foot.  There  was  a  hernia 
cerebri  (encephalocele  ?)  at  the  posterior  part  of  the  head.  The 
thoracic  and  abdominal  viscera  were  natural,  except  the  kid- 
neys. The  right  kidney  weighed  4  oz.  6  drs.;  the  left,  4  oz.  1 
dr.:  they  were  irregular  on  the  surface  from  numerous  project- 
ing cysts.  On  a  section  being  made  through  the  centre  of  each, 
it  was  found  that  all  traces  of  kidney  structure  had  disappeared, 
and  that  its  place  was  occupied  by  an  infinite  quantity  of  cysts 
of  diflterent  sizes,  forming  the  whole  mass  of  the  organ ;  the 
calices  were  in  part  normal,  but  large,  and  the  pelvis  of  each 
kidney  was  perfect,  with  the  exception  that  it  formed  a  blind 
sac,  with  no  opening;  that  is  to  say,  there  were  no  ureters.  The 
bladder  was  small  and  empty;  there  was  no  trace  of  ureters  on 
its  external  surface ;  but  internally,  at  the  spots  where  the 
ureters  should  have  entered,  there  were  small  imperforate 
papillae. 

The  structure  of  these  kidneys  was  examined  by  Dr.  Gull 
under  the   microscope.      He  could   not   detect   any   secreting 


CONGENITAL    CYSTIC    ])  EG  E  N  K  II  A 'I' J  O  N  .  503 

tissue,  and  considered  the  cysts  to  be  obstructed  and  dilated 
Malpighian  capsules.' 

The  degeneration  has  not  always  been  found  in  so  extreme  a 
degree  as  in  this  case  of  Dr.  Lever.  Generally,  some  remnants 
of  secreting  texture  (uriniferous  tubes  and  Malpighian  tufts) 
have  been  detected  in  the  interstices  between  the  cysts.  In 
some  cases  the  external  surface  is  smooth,  while  the  interior 
presents  a  spongy  or  cavernous  structure,  which,  under  the 
microscope,  resolves  itself  into  myriads  of  minute  cysts.  The 
researches  of  Virchow  and  Foster  have  fully  demonstrated,  that 
the  cysts  in  these  cases  are  originally  produced  by  dilatation  of 
short  sections  of  the  uriniferous  tubes  into  pouc?ies ;  these 
pouches  afterwards  become  enlarged  and  separated  from  each 
other,  and  at  length  form  distinct  cysts.  They  are  lined  with  a 
tessellated  epithelium,  and  contain,  at  iirst,  a  urinous  fluid,  which 
at  a  later  period,  when  the  cyst  attains  a  larger  size,  becomes 
albuminous. 

It  is  curious  that  malformations  of  the  pelvis  of  the  kidney, 
of  the  ureter,  bladder,  or  urethra,  or  of  some  other  part  of  the 
body,  nearly  always  coexist  with  congenital  cystic  degeneration 
of  the  kidneys.  Sometimes,  however,  the  lower  urinary  pass- 
ages are  perfectly  open. 

Virchow  flrst  pointed  out  the  mechanical  cause  of  this  dis- 
ease. In  all  the  cases  examined  by  him,  there  was  found  an  im- 
perforate state  (atresia)  of  the  straight  ducts  which  terminate  on 
the  papillae;  and  he  conjectures  that  this  had  arisen  from  intra- 
uterine inflammation  of  the  ducts  of  the  papillae,  which  ended 
in  adhesion  of  their  parietes  and  closure  of  their  calibre.  He 
further  believes  that  the  usual  cause  of  this  inflammation  is  the 
impaction  of  uric  acid  or  the  urates  (Harnsaure-infarct),  in  the 
straight  canals  {see  p.  474).  The  closure  of  the  excretory  ducts 
necessarily  causes  stagnation  and  accumulation  of  the  urine 
throughout  the  entire   organ,  and    leads  to    dilatation  of   the 

^  Dr.  Duffey  ("Dub.  Quart.  Journ.,"xli.  p.  438)  has  described  the  following  case 
in  an  anencephalous  foetus  at  the  full  time.  The  fourth  and  fifth  fingers  of  both 
hands  and  the  corresponding  toes  on  the  right  foot  were  united  by  a  web  up  to  the 
second  phalanges,  and  there  was  a  sixth  digit  similarly  united  to  the  entire  length 
of  the  fifth.  The  left  foot  was  normal.  The  abdomen  was  18  inches  in  circum- 
ference. There  were  two  tumors  found  in  the  abdomen,  which  proved  to  be  the 
kidneys,  lying  on  and  adherent  to  which  were  the  ovaries  and  Fallopian  tubes 
leading  to  a  bifid  uterus.  The  kidneys  presented  the  usual  lobulated  appearance 
of  the  foetal  organs,  but  on  section  numerous  small  transparent  cysts  were  found  of 
the  size  of  peas,  in  a  matrix  of  a  light  grayish  color,  from  which  they  could  not  be 
detached,  and  which  contained  a  clear  serous  fluid.  The  distinction  between  the 
cortical  and  medullary  portions  was  totally  obliterated,  but  the  outline  of  the 
calices  could  be  distinctly  traced.  The  ureters  were  pervious;  bladder  empty.  The 
right  kidney,  even  after  exposure  to  the  air  for  some  days,  weighed  6  oz. ;  the  left 
was  apparently  of  equal  size. 


504  CYSTIC    DEGENERATION    OF    THE    KIDNEYS. 

uriniferous  tubes  and  Malpighian  capsules,  and  the  ultimate  for- 
mation of  cysts, ^ 

4.  General  Cystic  Degeneration  of  the  Kidneys,  in  Adults. 
— This  is  a  somewhat  rare  condition,  though  most  museums 
contain  specimens.  There  are  two  very  fine  examples  in  the 
collection  of  the  Owen's  College.  In  this  form  of  disease  the 
organs  are  more  or  less  enlarged,  so  as  sometimes  to  weigh 
several  pounds,  and  to  constitute  tumors  in  the  abdomen  recog- 
nizable during  life.  Both  kidneys  are  always  aft'ected  ;  but  not, 
generally,  in  an  equal  degree.  The  substance  of  the  gland  is 
converted  into  a  mass  of  closely  aggregated  cysts,  lodged  in  an 
abundant  matrix  of  connective  tissue  {see  Figs.  63  and  64).  The 
cvsts  do  not  communicate  with  each  other,  nor  with  the  calices 
—except  in  rare  cases,  when  some  of  them  suppurate  and  open 
into  the  pelvis.  They  range  in  size  from  a  pin's  head  to  an 
orange,  and  have  walls  of  varying  thickness.  Their  contents 
also  vary:  some  contain  a  limpid  yellowish  or  reddish  serum; 
others  a  gelatinous  substance.  The  fluid  within  the  cysts 
always  contains  albumen,  but  not  urinary  ingredients.  The 
interior  of  the  cysts  is  lined  with  epithelium  usually  of  the  tes- 
sellated variety ;  and  sometimes  blood-disks,  pus-corpuscles,  and 
cholesterine  crystals  are  found  within  them.  In  far  advanced 
cases  the  secreting  tissue  of  the  kidney  is  almost  entirely  de- 
stroyed; more  frequently  remnants  of  renal  tissue  are  found  in 
the  fibrous  matrix  between  the  cysts  and  in  the  pyramidal 
portions.  The  pelvis,  ureter,  and  bladder  are  open,  and  usually 
healthy.  Two  or  more  cysts  may  become  confluent  by  absorp- 
tion of  some  parts  of  their  walls,  and  then  an  irregular  cavity  is 
produced,  with  fibrous  bands  or  freena  passing  from  side  to  side. 

Quekett  attributed  the  formation  of  these  cysts  to  dilatations 
of  the  Malpighian  capsules;  but  the  observations  of  Dr.  Conway 
Evans,^  and  Dr.  Bristowe,^  on  what  appear  to  have  been  incipi- 
ent cases,  lead  to  the  conclusion  that  they  are  formed,  as  in  the 
congenital  cases,  by  expansion  of  sections  of  the  uriniferous 
tubes,  and  occlusion  and  atrophy  of  the  intermediate  portions. 
Independent  sacs  are  thus  constituted,  which  at  first  are   so 

'  Koster  argues  that  this  view  is  incorrect.  He  attributes  the  origin  of  the  cystic 
kidney  to  an  abnormal  development  analogous  to  atresia  ani,  non-development  of 
the  urethra,  and  similar  conditions ;  and  urges  in  support  of  this  view  the  total 
absence  of  the  renal  calices  and  pelvis,  and  also  the  ureters  in  many  cases  of  this 
disease.  Kupfer's  investigations  into  the  development  of  the  kidney,  showing  that 
the  blastema  for  the  tubuli  uriniferi  is  developed  by  itself,  independently  of  the 
evolution  of  the  WolflBan  duct  (which  becomes  ureter  and  renal  pelvis),  will  if  con- 
firmed lend  greatly  to  strengthen  the  theory  advocated  by  Koster.  Origin  of  the 
Congenital  Kenal  Cystoid.  "  Nederlandsch.  Arch.  v.  G-en.  in  Naturkunde,  1867, 
translated  by  W.  D.  Moore,  Dub.  Quart.  Journ.,  xlvi.  256. 

2  Path.  Trans.,  vol.  v.  p.' 183.  -^  Ibid.,  vol.  ix.  p.  309. 


IN    ADULTS.  505 

niiiiute  that  they  can  only  be  seen  with  the  niicroBCOpe,  but  at  a 
liater  period  they  enhirge  into  visible  cystH.' 

The  clinical  history  of  these  cases  has  been  but  imperiectly 
studied.  Of  fifteen  cases  which  I  have  been  able  to  collect — 
including  one  contributed  by  myself — ten  were  men  and  live 
women;  most  of  them  were  about  the  middle  age;  ten  were 

Fig.  63. 


General  cystic  degeneration  of  the  kidney  in  an  adult — i'lom  a  preparation  in  the  Museum 
of  the  Manchester  Infirmaiy — one-fourth  the  actual  size. 

between  forty  and  fifty  years  of  age;  one  was  "  old,"  one  was 
thirty-nine,  and  the  youngest  thirty.  The  S3miptoms  during  life 
are  not  very  distinctive.  The  course  of  the  disease  is  essentially 
chronic;  the  secretion  of  urine  goes  on  to  an  advanced  period, 
without  marked  diminution — it  may  even  be  greatly  increased. 
An  unnaturally  low  density  of  the  urine  would  appear  to  be  a 
tolerably  constant  feature,  at  least  in  advanced  cases.  The  end 
(if  the  patient  die  of  the  renal  affection  and  not  of  some  compli- 
cation) is  usually  sudden,  with  manifestations  of  uraemic  coma 
and  convulsions.    In  a  case  cited  by  Eayer,  there  were  recurrent 

1  A  form  of  cystic  kidney  somewhat  different  from  that  described  in  the  text 
is  found  associated  with  a  similar  degeneration  of  the  liver.  It  must  not  be  con- 
founded with  putrefactive  changes  in  these  organs.  (See  Brit.  Med.  Jouru..  1884, 
i.  p.61.) 


606  CYSTIC    DEGENERATION    OF    THE    KIDNEYS. 

attacks  of  excessively  violent  lumbar  pains,  severe  gastric  symp- 
toms, abundant  discharge  of  a  watery  urine,  and  lastly,  convul- 
sions, delirium,  and  coma.  In  another  case  recorded  by  the 
same  author,  the  patient — whose  only  previous  suiFering  con- 
sisted in  old-standing  dyspeptic  symptoms — was  suddenly  seized 
with  coma,  resolution  of  the  members,  and  convulsive  upturning 
of  the  eyes,  which  proved  fatal  in  twelve  hours.  In  two  cases 
reported  by  Dr.  Whipham,*  the  closing  symptoms  were  bronchitis 
with  urgent  dyspepsia,  without  coma  or  convulsions.  Albumin- 
uria and  recurrent  hpematuria  are  among  the  most  constant  symp- 
toms. In  Dr.  Conway  Evans's  case,  the  urine  was,  however,  not 
albuminous  on  the  day  of  death,  nor  two  months  previously. 
Death  was  caused  in  this  case  by  cardiac  disease,  and  the  renal 
degeneration  was  not,  comparatively  speaking,  very  far  ad- 
vanced.^ 

The  latent  and  insidious  course  of  the  disease,  with  sudden 
stormy  termination,  is  well  illustrated  in  the  following  example, 
which  occurred  in  my  practice  : 

On  Saturday  evening,  October  28,  1871,  I  was  requested  by  Mr.  R. 
Heathcote  to  see  Mrs.  S.,  a  married  lady  of  forty-eight.  He  informed 
me  that  the  patient  was  the  mother  of  several  children,  of  whom  the 
youngest  was  four  years  old.  The  menses  still  continued,  but  irregu- 
larly. Some  three  months  previously  she  had  been  under  his  care  for 
neuralgia  and  anssmia,  which  yielded  readily  to  quinine  and  iron.  Since 
then  she  had  been  in  her  usual  fair  health  up  to  the  previous  Monday, 
when  she  was  suddenly  attacked  with  vomiting.  The  vomiting  con- 
tinued, almost  incessantly,  during  the  current  week,  and  no  urine  had 
been  voided  since  Tuesday.  Early  on  Saturday  morning,  she  was  seized 
with  an  epileptic  fit ;  this  was  succeeded  by  two  more  in  the  course  of 
the  day.  At  noon,  about  six  ounces  of  urine  were  withdrawn  by  catheter. 
This  was  of  normal  appearance,  but  it  contained  a  moderate  amount  of 
albumen. 

When  I  saw  her  in  the  evening,  the  vomiting  still  persisted,  accom- 
panied with  devouring  thirst.  The  patient  was  nearly  fully  conscious. 
There  was  great  restlessness,  with  tossing  of  the  limbs  and  moaning. 

^  Path.  Soc  Trans.,  vol.  xxi.  p.  244. 

^  [Three  cases  of  cystic  kidney  have  died  in  the  Manchester  Eoyal  Infirmary 
during  the  last  three  years.  The  first  case  had  shown  mental  depression  and 
stupor  for  a  fortnight  before  admission,  and  died  a  weelt  afterwards  with  ursemic 
symptoms.  The  second  case  died  from  ursemic  coma  two  days  after  admission, 
and  no  reliable  history  could  be  obtained.  Before  death  the  urine  was  scanty  and 
contained  a  large  quantity  of  blood.  Both  kidneys  were  cystic,  and  the  left  had 
two  ureters,  proceeding  from  entirely  separate  pelves  of  the  kidney  ;  the  two 
divisions  of  the  kidney  were  equally  affected  by  the  cystic  transformation.  In  the 
third  case,  the  kidney  change  was  found  only  in  the  regular  course  of  a  post- 
mortem examination.  The  patient  had  died  from  chronic  cerebral  meningitis, 
and  during  life  there  was  neither  albuminuria  nor  any  other  symptom  of  kidney 
mischief.  Microscopic  examination  showed  a  certain  amount  of  true  kidney  struc- 
ture, but  the  glomeruli,  renal  tubes,  and  arteries  were  surrounded  by  a  great 
quantity  of  fibrous  tissue. — R.  M.] 


ILLUSTRATIVE    CASES.  507 

The  bowels  had  been  opened  by  injection.     The  pupils  were  strongly 
contracted,  and  the  tongue  was  dry. 

On  examining  the  loins,  I  detected  two  soft  elongated  swellings  or 
tumors,  one  on  each  side,  in  the  renal  regions.  The  tumors  appeared 
about  the  same  size,  and  might  be  about  as  large  as  a  cocoanut,  but  of 
greater  length.  They  did  not  fluctuate.  Both  flanks  were  dull  on  per- 
cussion. ^  I  ventured  to  express  the  opinion  that  we  had  to  do  with  cystic 

Fig.  64. 


*/"* 

---/. 


'  %K 


Left  kidney  of  Mrs  S. — showing  complete  cystic  transformation  of  the  organ — about  onf-half 

the  actual  size. 

degeneration  of  the  kidneys,  basing  the  diagnosis  on  the  urtemic  com- 
plexion of  the  symptoms,  the  existence  of  two  soft  renal  tumors  with 
albuminuria.  If  this  diagnosis  were  correct,  there  could  be  no  question 
of  curative  treatment.  It  w^as  suggested,  however,  that  the  lumbar 
swellings  might  possibly  consist  of  fecal  accumulation.  The  treatment 
was  accordingly  directed  to  remove  these.     Sulphate  of  magnesia  ene- 


508  CYSTIC    DEGENERATIOiSr    OF    THE    KIDNEYS. 

mata  were  ordered  to  be  repeatedly  administered,  and  belladonna  in  pill 
was  given  by  the  mouth.  Nothing  availed.  In  the  course  of  the  night 
the  patient  had  six  epileptic  fits,  and  when  we  saw  her  on  Sunday  morn- 
ing she  was  barely  conscious.  The  stomach  was,  however,  much  quieter, 
and  she  had  been  able  to  retain  a  considerable  amount  of  liquid  nourish- 
ment. No  urine  had  been  voided,  but  16  ounces  were  withdrawn  by 
catheter.  This  was  pale  amber,  clear,  faintly  alkaline ;  it  was  slightly 
albuminous  (abt.  -^■^),  specific  gravity  1013.  After  it  had  been  kept  for 
twelve  hours,  it  deposited  a  copious  sediment  of  triple  and  amorphous 
phosphates,  and  spheres  and  dumb-bells  of  urate  of  ammonia,  but  no  casts 
of  tubes  could  be  detected.  During  the  course  of  Sunday  and  Sunday 
night,  the  epileptic  seizures  recurred  again  and  again,  and  death  took 
place  on  Monday  morning,  after  an  illness  of  almost  exactly  a  week. 

Autopsy. — The  body  was  tolerably  well  nourished.  Only  the  abdo- 
men was  examined.  All  the  organs  in  it  were  healthy  except  the 
kidneys.  The  kidneys  presented  typical  examples  of  cystic  degenera- 
tion (see  Fig.  64).  They  were  considerably  enlarged,  and  appeared  to 
consist  entirely  of  a  congeries  of  large  and  small  cysts.  The  right 
weighed  28  ounces,  and  the  left  26  ounces ;  they  were  of  an  elongated, 
oval  form,  between  eight  and  nine  inches  in  length,  and  four  inches  in 
thickness.  On  section  of  the  right  kidney,  not  a  particle  of  normal 
renal  tissue  could  be  seen  ;  the  entire  organ  was  converted  into  cysts 
and  intervening  fibrous  tissue.  The  left  kidney  was  not  so  completely 
degenerated.  The  cortical  substance  was  all  transformed  into  cysts  and 
fibrous  matrix ;  but  the  pyramids  were  not  wholly  destroyed.  The 
papillse  could  still  be  distinguished,  together  with  a  short  length  of  the 
annexed  portions  of  the  pyramids.  These  presented  a  pale-red  striated 
appearance.  Judging  roughly,  about  a  twentieth  part  of  the  renal  tis- 
sue might  be  said  still  to  exist,  and  on  the  services  of  this  remnant  the 
patient's  life  must  have  latterly  depended.  It  is  most  strange  that  life 
could  have  been  protracted  until  this  extreme  degree  of  destruction  had 
been  reached 

The  cysts  varied  in  size  from  a  pea  to  a  walnut ;  most  of  them  were 
as  large  as  marbles.  Their  contents  were  (generally)  a  clear  yellow, 
highly  albuminous  serum.  Some  were  opaque  and  semi-solid,  either  yel- 
lowish or  dark  red.  These  diflferences  depended  on  two  circumstances, 
namely,  the  degree  of  inspissation  and  degeneration  of  the  contents,  and  on 
eflTusion  of  blood  into  the  cysts.  Under  the  microscope,  the  yellow  semi- 
solid contents  were  found  to  be  composed  of  free  fatty  and  albuminous 
granules  and  large  numbers  of  so-called  "granular  corpuscles.'"  A  few 
plates  of  cholesterine  and  crystals  of  triple  phosphate  were  also  found. 
No  traces  of  urea  or  uric  acid  could  be  detected. 

The  following  example  from  Bright's  memoir  on  abdominal 
tumors  ("  ISTew  Syd.  Soc.'s  Publications,"  vol,  vi.  p.  208)  show^s 
the  successive  appearance  of  a  renal  tumor  first  on  the  left, 
then  on  the  right  side  of  the  abdomen,  and  gives  an  excellent 
picture  of  the  disease. 

Mr. ,  about  thirty,  seen  by  Dr.  Bright,  November,  1835.     His 

aspect  bespoke  a  man  laboring  under  some  formidable  chronic  disease. 


ILLUSTRATIVE    CASES. 


509 


He  was  evidently  much  emaciated  and  greatly  enfeebled.  He  passed  a 
moderate  quantity  of  urine,  which  was  acid,  light-colored,  and  albu- 
minous. His  present  illness  dated  about  two  years  back,  at  which  period 
he  had  decided  htcmaturia,  which  continued  at  intervals  for  some  time. 
Since  that,  he  had  never  considered  himself  in  health  ;  he  had,  however, 
pursued  his  usual  occupation  till  lately,  but  for  the  last  four  months  he 
had  been  more  decidedly  an  invalid.  A  tumor  was  to  be  distinctly 
ascertained  in  the  left  lumbar  space,  where  it  appeared  pretty  firmly 
fixed  (see  Fig.  65).     It  might  be  fairly  grasped  by  the  hand  so  placed 

Fro.  65 


Diagram  showing  tlie  situation  of  the  tumors  in  the  case  of  a  patient  with  general  cystic  degeneration 
of  both  kidneys  (after  Bright). 


that  the  thumb  was  near  the  spine,  and  the  finger  advanced  into  the 
hypochondriac  region.  The  history  of  the  case,  the  state  of  the  urine, 
and  the  situation  of  the  tumor,  all  led  to  the  easy  decision  that  the  tumor 
depended  on  enlarged  kidney.  When  felt  in  front,  the  spleen,  or  the 
descending  colon  loaded  with  feces,  suggested  themselves ;  but  the  fact 
that  it  seemed  to  belong  rather  to  the  posterior  than  the  anterior  "part  of 
the  abdomen,  and  its  fixed  feel  would  have  removed  these  doubts  had 
not  the  history  of  the  case  pointed  so  distinctly  to  the  kidney.  The 
exact  nature  of  the  renal  disease  was  less  obvious.  The  very  consider- 
able enlargement  of  the  organ  did  not  belong  to  the  usual  history  of 
albuminous  urine,  and  the  general  loss  of  power  bespoke  some  formid- 
able organic  disease.  He  was  ordered  a  well-regulated  nourishing  diet. 
The  emplast.  ammoniaci  c.  hydrarg.  was  applied   to  the  seat  of  the 


510  CYSTIC    DEGENERATION"    OF    THE    KIDNEYS. 

tumor;  and  the  uva  ursi  in  infusion,  and  slight  alkaline  preparations, 
were  directed  to  be  taken.  Under  this  treatment  flattering  reports  were 
at  first  received,  but  the  disease  advanced,  all  the  symptoms  became 
worse,  enlargement  of  the  right  kidney  also  became  pex'ceptible,  the 
urine  remained  moderately  coagulable  (about  a  pint  and  a  half  in  twenty- 
four  hours),  and  he  suffered  a  great  deal  of  pain  at  the  neck  of  the 
bladder,  from  the  frequent  passing  of  fibrinous  coagula  of  a  slight  pinkish- 
yellow  color,  about  an  inch  long,  and  apparently  moulded  by  the  urethra. 
His  emaciation  became  extreme,  and  he  had  frequent  returns  of  hsema- 
turia.  From  the  middle  of  February  he  was  completely  confined  to  his 
bed,  expecting  death  daily.  In  the  first  week  of  April  he  experienced 
some  slight  convulsive  seizures,  and  fell  into  a  state  of  coma  for  a  few 
hours  before  his  death,  which  occurred  about  the  10th  of  April. 

Both  kidneys  presented  most  extreme  specimens  of  vesiculated  dis- 
ease ;  the  left  was  the  largest,  and  was  probably  eight  or  ten  times  the 
natural  size,  while  the  right  was  at  least  six  times  the  size  of  the  healthy 
kidney.  The  whole  appeared  made  up  of  a  congeries  of  vesicles,  from 
the  size  of  a  pigeon's  egg  to  a  pea ;  and  the  substance  of  the  kidney  was 
almost  obliterated  ;  nothing  but  a  thin  layer  of  secreting  structure  re- 
maining, and  that  greatly  altered  from  the  natural  texture.  The  pelvis 
of  the  kidney  and  the  mamillary  processes  alone  retained  a  tolerably 
healthy  appearance;  the  lining  membrane  of  the  pelvis  had  no  undue 
vascularity,  and  was  perfectly  smooth ;  the  mammillary  processes,  though 
somewhat  flattened,  showed,  when  divided,  the  healthy  organization;  the 
ureters  were  healthy,  but  the  renal  vessels,  particularly  the  veins,  were 
large.  The  other  viscera  were  healthy,  and  the  bladder  contained  half 
a  pint  of  urine. 

The  enormous  size  which  the  kidneys  sometimes  attain  in  this 
disease,  and  the  abrupt  termination  of  life,  are  illustrated  by  the 
following  remarkable  case  recorded  by  Dr.  Hare  ("  Path.  Soc. 
Trans.,"  1850-1,  p.  131) : 

A  man,  set.  46,  was  seen  in  January,  1850,  for  an  attack  of  pleurisy. 
Under  treatment,  he  recovered  and  returned  to  his  business,  until  the 
5th  of  March,  when  Dr.  Hare  was  again  called  in.  The  night  pre- 
viously he  had  passed  a  considerable  quantity  of  very  bloody  urine, 
which  had,  apparently,  given  him  great  relief  from  a  constant  pain  he 
had  in  the  left  loin.  On  examination  of  the  abdomen,  which  had  lately 
become  larger  than  usual,  a  tumor  was  found,  extending  from  the  car- 
tilages of  the  false  ribs  of  the  left  side  to  about  an  inch  below  the  level 
of  the  umbilicus,  and  forwards  to  within  about  an  inch  of  the  median 
line.  On  percussion  it  was  dull,  and  there  was  no  interval  of  resonance 
between  the  tumor  and  the  cartilages  of  the  ribs;  and  the  dulness  on 
percussion  extended  upwards  beyond  the  lower  margin  of  the  latter; 
the  anterior  border  was  rounded,  but  presented  no  signs  of  fluctuation. 

In  April,  a  considerable  alteration  was  observed  to  have  taken  place 
in  the  turaiOr ;  it  still  felt  solid  and  without  fluctuation  ;  the  lower  border 
extended  an  inch  and  half  below  the  level  of  the  anterior  superior  spine 
of  the  ilium.  Its  anterior  border  was  deeply  notched  on  a  level  with 
the  umbilicus,  and  percussion  was  resonant  at  this  notch,  as  also  for 


ILLUSTRATIVE    CASES.  511 

some  distance  obliquely  across  the  tumor.  It  presented  very  much  the 
physical  signs  of  a  double  tumor,  or  of  two  tumors;  on  placing  (jne 
hand  over  the  lower  part  of  the  abdomen,  and  pressing  with  the  other 
against  the  left  loin,  although  the  tumor  could  i)e  very  slightly  moved, 
it  appeared  to  move  as  one  mass.  iJr.  Bright,  who  also  saw  the  case, 
spoke  confidently  as  to  its  being  "all  kidney  with  intestine  passing  C)ver 
it,  and  thus  giving  the  appearance  of  two  tumors ;"  there  was  also  now 
a  slight  interval  of  resonance  between  the  cartilages  of  the  false  ribs 
and  the  tumor.  The  urine,  which  had  contained  blood  two  or  three 
times,  was  now  clear. 

On  the  9th  of  December,  he  fell  suddenly  from  his  chair,  convulsed 
and  insensible  ;  this  was  followed  by  sleepiness,  numbness  in  both  hands, 
and  frequent  twitchings. 

On  the  12th,  when  seen  by  Dr.  Hare,  he  had  a  vacant  expression, 
wandered  a  little,  but  answered  sharply  when  spoken  to;  there  were 
slight  twitchings  of  the  upper  extremities.  Pulse  72;  feet  and  legs 
rather  edematous.  The  tumor  appeared  much  the  same  as  in  April, 
except  that  it  extended  rather  beyond  the  median  line,  and  that  the 
notch,  at  its  anterior  border,  was  less  marked.  Urine  pale,  without 
sediment,  specific  gravity  1008,  containing  one-tenth  albumen. 

On  the  13th,  he  had  two  fits,  somewhat  similar  to  those  on  the  9lh, 
and  he  died  on  the  16th,  probably  from  the  presence  of  urea  in  the 
blood. 

Autopsy. — The  left  side  of  the  abdomen  was  occupied  by  an  enormous 
tumor  which  proved  to  be  the  left  kidney,  the  intestines  being  pushed 
over  to  the  right  side.  The  tumor  also  extended  under  the  intestines 
half-way  across  the  right  half  of  the  abdomen ;  its  upper  surface  was 
adherent  to  the  diaphragm,  and  it  had  so  compressed  the  spleen,  that 
the  latter  formed,  as  it  were,  a  cap  to  the  kidney ;  the  pancreas  was 
carried  forwards,  and  was  adherent  transversely  to  the  anterior  surface 
of  the  tumor,  near  its  upper  part ;  the  descending  colon,  somewhat  con- 
tracted, was  likewise  adherent  to  its  anterior  surface,  but  perpendicularly, 
so  as  to  divide  it  into  nearly  equal  portions. 

The  kidney  measured  151  inches  in  length,  9J  in  breadth,  and  about 
23  in  circumference,  and  weighed  exactly  16  lbs.;  it  still  retained  some- 
what the  kidney  shape,  but  its  surface  was  uneven  from  the  projection 
of  diflTerent  cysts.  It  consisted  of  one  enormous  congeries  of  cysts,  vary- 
ing in  size  from  a  small  pea,  to  a  cavity  holding  more  than  a  pint  of 
fluid ;  the  larger  cysts  were  at  the  surface,  the  smaller  ones  being  about 
the  centre;  many  of  the  smaller  cysts  projected  more  or  less  into  the 
cavity  of  the  larger  ones :  they  presented  different  tints,  from  a  dark 
purple,  to  a  light  straw-color  (the  latter  much  more  rare  than  the  for- 
mer), according  to  the  color  of  the  contained  fluids ;  the  darker  fluid 
was  generally  the  thickest,  and  at  the  bottom  of  those  cysts  the're  was 
more  or  less  of  a  dirty-red  grumous-looking  matter,  which  was  wanting 
in  those  containing  the  lighter- colored  fluid.  The  thickness  of  their 
walls  varied  generally  in  proportion  to  their  size,  the  larger  having  the 
thickest  parietes.  No  trace  of  the  proper  structure  of  the  kidney  was 
discoverable.  The  fluid,  under  the  microscope,  showed  an  immense 
number  of  blood-disks  (more  abundant  in  the  darker  fluids^,  some  oil 


512  CYSTIC    DEGENERATION    OF    THE    KIDNEYS. 

globules,  exudative  corpuscles,  portions  of  the  tubules  of  the  kidney, 
and  a  considerable  number  of  plates  of  cholesterine. 

The  right  kidney  presented  incipient  disease  of  the  same  kind,  and 
was  enlarged  to  double  its  natural  size. 

There  was  a  slight  hypertrophy  of  the  heart,  and  a  hernia  above  the 
umbilicus  ;  the  remaining  viscera  were  natural. 

In  the  following  case  described  by  Dr.  Gray  ("Path.  See. 
Trans.,"  vol.  vi.  p.  267),  the  disease  appeared  to  be  occasioned 
by  external  violence :  death  was  not  preceded  by  cerebral 
sj-mptoms,  but  by  vomiting  and  hiccough,  possibly  of  ursemic 
origin. 

A  man,  set.  40,  much  emaciated  and  ansemic,  who  had  been  very  in- 
temperate when  young,  was  admitted  into  St.  George's  Hospital,  March 
7,  1855. 

He  dated  the  commencement  of  his  present  illness  seven  years  ago, 
when  he  received  a  severe  injury  of  the  back  ;  for  some  time  after  this 
accident  he  passed  blood  in  his  urine.  He  then  partially  recovered,  but 
during  the  three  following  winters  he  often  passed  a  small  quantity  of 
blood,  and  suffered  much  from  pain  in  his  loins.  Five  weeks  before  his 
admission  into  the  hospital,  he  fell  on  his  right  hip,  and  then  the  hsema- 
turia  and  pains  in  the  loins  returned  in  an  aggravated  form.  When 
first  admitted,  he  was  in  a  very  weak  and  exhausted  condition  ;  the 
pulse  was  exceedingly  feeble,  and  the  urine  was  loaded  with  blood  ; 
vomiting  and  hiccough  supervened,  and  he  died  exhausted  on  the  10th 
of  March. 

Autopsy. — There  was  extensive  cystic  transformation  of  both  kidneys ; 
and  to  such  an  extent  had  the  disease  proceeded  that  the  natural  struc- 
ture of  the  glands  could  in  no  part  be  detected.  The  right  kidney 
weighed  3  lbs.  10  ozs. ;  the  left,  3  lbs.  They  were  each  about  ten  inches 
in  length,  lobulated  on  their  surfaces,  and  composed  of  numerous  sepa- 
rate cysts,  varying  in  size  from  a  pea  to  a  small  apple.  The  contents  of 
some  of  the  cysts  were  transparent  and  colorless,  of  others  faint  yellow, 
of  others  chocolate.  The  color  in  these  last  appeared  to  depend  on 
blood-disks  and  their  debris.  The  pelvis  of  the  kidney  and  the  ureter 
were  not  dilated. 

All  the  other  organs  were  natural,  with  the  exception  of  the  lungs, 
which  were  oedematous. 

The  primary  lesion  in  this  class  of  cases  is  possibly  the  same 
as  in  the  congenital  cases,  and  consists  in  a  progressive  occlusion 
of  the  ducts  of  the  pyramids,  leading  at  a  later  period  to  sac- 
cular dilatations  of  the  tubes  of  the  cortex,  and  finally  to  the 
formation  of  myriads  of  separate  cysts.  The  cause  of  the  oc- 
clusion, in  most  cases,  is  probably  an  interstitial  inflammation, 
leading  to  the  formation  of  contractile  fibrous  tissue.  Thorn 
(Inaug.  Diss.  Bonn.,  1882)  found  in  one  case  that  the  inflamma- 
tion had  begun  in  the  ureter  and  pelvis  of  the  kidney,  and  had 


NATURE    AND    TREATMENT.  513 

thence  proceeded  to  the  pyramidal  portion.  It  in  [)robab]o  that 
the  epithelium  of  the  tubes  also  undergoes  Honio  active  change, 
but  of  what  nature  is  uncertain.'  Conceivaljly  the  calibre  of 
the  ducts  may  be  obstructed  by  plugs  of  coagulated  blood.  In 
Dr.  Gray's  case,  just  related,  the  latter  explanation  would  appear 
to  be  a  not  improbable  one. 

General  cystic  degeneration  has  evident  affinities  with  the 
granular  atrophic  forms  of  Bright's  disease,  and  probably 
requires  a  similar  treatment. 

^  See  Cornil  and  Brault,  Siir  la  Pathologic  du  Kein,  Paris,  1884,  p.  203.  Chot- 
insky  (Inaug.  Diss.  Bonn.,  1882)  asserts  that,  in  the  fcetal  form,  proliferation  of 
the  epithelium  plays  a  part  in  blocking  the  tubes. 


33 


CHAPTER  X. 

CANCER  OF  THE  KIDNEY. 

Cancerous  growths  of  the  kidney  may  be  primary  or  secondary. 
Primary  cancer  is  attended  by  its  proper  symptoms  and  physical 
signs :  it  runs  a  distinctive  course,  and  constitutes  the  cause  of 
death.  Secondary  cancer,  on  the  other  hand,  occasions  neither 
symptoms  nor  physical  signs  :  it  is  either  a  part-manifestation  of 
a  general  cancerous  cachexia,  or  an  incident  in  the  progress  of 
primary  cancer  of  some  other  organ  ;  and  its  existence  is  usually 
unsuspected  until  the  autopsy.  It  is  therefore  necessary  to  con- 
sider the  two  conditions  apart,  the  latter  indeed  very  briefly,  as 
it  has  little,  if  any,  clinical  interest. 

A.— PEIMAKY   CANCEK   OF   THE    KIDNEY. 

The  following  description  is  based  on  an  analysis  of  68  cases, 
of  which  64  were  collected  from  various  sources,  and  4  con- 
tributed by  myself.  In  all  of  them  the  disease  was  followed  to 
its  fatal  termination,  and  the  diagnosis  verified  by  dissection 
after  death. 

The  cases  naturally  fall  into  two  groups — children  and  adults; 
and  it  will  be  desirable  occasionally  to  distinguish  the  one  class 
from  the  other.  The  first  group  embraces  25  cases  under  the 
age  of  ten  years — indeed  all,  except  3,  under  five  years.  The 
second  group  includes  43  adults  between  the  ages  of  nineteen 
and  seventy. 

Morbid  Anatomy. — The  species  of  cancer  found  in  the  kidney 
is  almost  invariably  the  encephaloid  (fungus  hsematodes).^  It 
varies  greatly  in  consistence  and  vascularity.  In  one  instance 
it  is  described  as  being  as  soft  as  the  milt  of  a  fish ;  more  com- 
monly it  is  about  as  hard  as  human  brain.  The  mass  is  seldom 
of  uniform  consistence  throughout,  and  it  is  frequently  the  site 
of  extensive  hemorrhages.  Cavities  containing  as  much  as  a 
pint  or  more  of  clotted  or  fluid  blood,  or  of  blood  mixed  with 

1  Two  cases  are  reported  in  the  Path.  Soc.  Trans.,  xxi.  pp.  239,  241,  in  one  of 
which  Mr.  De  Morgan  found  the  cancerous  matter  arranged  in  a  villous  manner  ; 
and  in  the  other,  recorded  by  Dr.  Murchison  (a  case  of  villous  disease  of  the 
bladder),  the  mucous  membrane  lining  the  pelvis  and  calices  of  both  kidneys  was 
studded  with  long  villous  processes. 


MORBID    ANATOMY.  515 

cancerous   detritus,   have    sometimes    been    found    within    the 
tumor.^ 

Scirrhus  is  very  rare  in  the  kidney.  Wilson  mentions  such  a 
condition,  but  his  description  is  vague.  Rayer  in  one  instance 
found  a  mass  resembling  mammary  scirrhus  in  the  midst  of  an 
encephaloid  kidney  ■?  and  Dr.  Walshe,  among  the  unpublished 
drawings  of  Carswell,  discovered  one  of  scirrhus  of  the  kidney: 
"the  entire  organ  was  converted  into  a  gray-colored  substance, 
somewhat  transparent,  and  of  the  hardness  of  fibrous  tissue.  It 
was  intersected  in  various  directions  by  pale-colored  bands  which 
were  opaque  and  lirmer  than  the  intermediate  gray  substance. 
It  yielded  only  a  small  quantity  of  serosity  on  pressure,  and  pre- 
sented few  or  no  bloodvessels."  (Walshe,  loc.  cit.,  380.) 

Colloid  cancer  has  been  occasionally  found  forming  a  part  of 
an  encephaloid  kidney. 

Epithelioma  has  not,  so  far  as  I  know,  been  found  in  the  kid- 
ney in  the  primary  form  in  more  than  two  cases.  In  one  case 
published  by  Robin  the  right  kidney  of  a  man  aged  fifty-one 
was  replaced  by  a  large  mass  of  adventitious  tissue,  of  which 
part  was  soft  and  part  hard.  Both  portions  were  composed  of 
cells  of  epithelial  character,  most  of  them  closely  approaching 
the  appearance  of  pavement  epithelium,  and  attaining  in  the 
softer  portions  enormous  dimensions.  Some  of  the  largest 
measured  -^  of  a  millimetre  in  length.  ISTone  were  found  dis- 
posed in  nests  as  in  an  ordinary  cutaneous  epithelioma.^  The 
second  case  was  observed  by  Waldeyer,  and  quoted  by  Birch- 
Hirschfeld  in  his  "  Lehrbuch  der  Pathologic,"  p.  1041. 

Encephaloid  invades  the  kidney  sometimes  in  the  nodular, 
sometimes  in  the  infiltrated,  form.  It  always  begins  in  the 
cortical  substance,  and  afterwards  involves  the  pyramids.  Th 
epithelium  of  the  renal  tubules  is  first  afi'ected,  and  then  the 
connective  tissue.*  The  tunica  propria  is  commoul}^  thickened 
into  a  strong  fibrous  membrane. 

When  the  whole  organ  is  uniforml}^  infiltrated,  its  natural 
shape  and  position  may  be  tolerably  preserved,  even  when  it  is 

1  The  late  Dr.  Hilton  Fagge  described  a  peculiar  variety  of  cancer  of  the  kid- 
ney, in  which  fatty  degeneration  had  occurred,  and  which  he  stj-led,  after  Cornil 
and  Kanvier,  Carcinoma  lipomatosum.     (See  Path.  Trans.,  vol.  xxvii.  p.  204.) 

2  A  similar  case  is  reported  by  Dr.  E.  E.  Townsend,  Jr.,  of  Cork.  (Dub.  Quart. 
Journ.,  xlv.  219.) 

^  Ch.  Robin.  Memoire  sur  I'Epithelioma  du  Rein.  Paris,  1855.  See  also 
Lebert,  Anat.  Pathol.,  ii.  351.  Mr.  Hoyle,  in  a  patient  w^io  died  in  the  Man- 
chester Royal  Intirmary,  found  epitheliomatous  nodules  in  the  kidney  secondaiy  to 
similar  growths  in  the  lungs,  and  in  each  organ  describes  cell-nests.  (Joui'n.  of 
Anat  and  Phys.,  vol.  xvii.  p.  509.) 

*  Cattani  w^as  able  in  one  case  to  trace  the  development  of  the  cancer  cells  from 
the  renal  epithelium.  Dr.  Norman  Moore  observed  a  similar  appearance,  and 
Dr.  Sharkey  traced  the  cancer  cells  to  proliferation  of  the  cell-lining  of  Bowman's 
capsule.     (Path.  Trans.,  vol.  xxxiii.) 


516  CANCER    OF    THE    KIDNEY. 

enlarged  to  many  times  its  original  volume.  But  when  a  nodule 
grows  from  one  end  of  the  gland,  leaving  the  remainder  exempt, 
an  irregular  tumor  is  formed,  which  may  assume  shapes,  and 
grow  into-  situations  very  embarrassing  for  the  diagnosis.  The 
exempted  portions  rarely  preserve  their  healthy  state;  the 
secreting  structure  wastes  and  degenerates  ;  or  it  suppurates — 
though  this  is  rare. 

It  is  a  marked  characteristic  of  primary  renal  cancer,  that  it 
forms  a  tumor  generally  of  large,  often  of  gigantic  proportions, 
which  may  stretch  from  the  loin  to  the  umbilicus,  and  from 
beneath  the  ribs  to  the  pubes,  and  weigh  many  pounds.  In  31 
out  of  our  68  cases,  exact  information  is  given  as  to  the  weight 
of  the  tumor.  In  16  children  its  average  weight  was  8J  lbs.; 
the  smallest  was  1  lb.  9  oz.  and  the  largest  31  lbs.!  In  15  adults 
the  average  weight  of  the  tumor  was  9J  lbs.;  in  one  case  the 
growth  was  about  the  size  and  weight  of  the  natural  kidney ;  in 
another  it  weighed  15  oz.;  in  two  others  it  weighed  IJ  lb.;  in 
several  it  varied  from  3  to  11  lbs.,  and  in  two  attained  a  weight 
of  27  lbs.  The  enormous  masses  found  in  young  children  are 
really  remarkable.  In  one  example,  recorded  by  Mr.  Spencer 
Wells,  a  growth  weighing  between  16  and  17  lbs.  was  taken 
from  the  body  of  a  child  only  four  years  of  age  ("  Path.  Soc. 
Trans.,"  xiv.  179). 

The  surface  of  an  encephaloid  kidney  is  usually  soft,  irregu- 
larly lobulated,  and  of  unequal  consistence.  I^Tot  unfrequently 
it  yields  a  deceptive  sense  of  fluctuation,  especially  in  certain 
spots. 

Renal  encephaloid  is  liable  to  the  same  accidents  (degenera- 
tion, softening,  suppuration,  hemorrhage)  as  soft  cancer  else- 
where. In  an  instance  mentioned  b}^  Bright,  the  softened  mass 
burst  into  the  peritoneum ;  in  another,  by  Rayer,  a  cancer  of 
the  right  kidney  ulcerated  into  the  duodenum ;  in  a  third,  by 
Abele,^  the  disease  broke  through  the  abdominal  parietes  a  fort- 
night before  death,  and  formed  a  fungous  ulcer  through  which 
a  portion  of  the  colon  protruded  and  ultimately  mortified. 

The  tumor  generally  contracts  extensive  adhesions  to  the  sur- 
rounding parts.  The  colon  is  invariably  found  in  front  of  the 
growth — though  sometimes  flattened  and  empty.  The  other 
abdominal  viscera  are  thrust  aside  as  the  tumor  enlarges :  the 
small  intestines  are  pushed  over  into  the  opposite  flank.  When 
the  growth  afiects  the  right  kidney,  the  liver  is  displaced  to  the 
left,  often  twisted  on  its  transverse  axis  so  that  its  upper  surface 
takes  a  vertical  direction  and  applies  itself  to  the  costo-abdomi- 
nal  wall.  This  distortion  has  been  especially  observed  where, 
as  in  Doderlein's  case,  the  growth  protrudes  from  the  upper  end 

1  Schmidt's  Jahrb.,  Bd.  v.  S.  379 


MORBID    ANATOMY.  517 

of  the  kidney,  and  makes  its  way  into  the  ri^ht  Ijypochondriun). 
When  the  tumor  is  constituted  by  the  left  kidney  tlie  stomacli 
is  pushed  to  right,  and  the  s[)leen  carried  Ijigh  up  into  the  vault 
o*f  the  diaphragm.'  The  thoracic  viscera  are  displaced  upwards 
more  or  less  accordir)g  to  the  bulk  of  the  tumor,  and  in  various 
directions  according  to  the  side  affected.  Among  other  effects 
on  the  adjacent  parts,  caries  of  the  vertebra?  was  twice  found  : 
more  or  less  compression  of  the  inferior  cava  generally  exists 
towards  the  later  periods,  occasioning  codema  of  the  legs  and 
sometimes  (though  rarely)  ascites. 

The  pelvis  of  the  kidney  was  found  generally  more  or  less 
involved,  and,  in  the  majority  of  cases,  the  ureter  was  perma- 
nently occluded  by  extension  of  the  cancerous  growth  into  it, 
or  by  blood-clots,  or  by  the  pressure  of  the  main  tumor. 

The  renal  veins  in  several  instances  contained  encephaloid 
matter ;  and  in  some  of  the  cases  it  could  be  traced  as  far  as  the 
vena  cava. 

In  the  overwhelming  majority  of  cases  only  one  kidney  was 
affected.  Out  of  67  instances  which  supply  information  on  this 
point,  the  disease  was  confined  to  one  kidney  60  times.  In  seven 
cases  both  kidneys  were  involved ;  but  in  three  only  of  these 
did  the  disease  appear  to  be  primary  on  both  sides;  in  the  other 
four  one  kidney  was  the  seat  of  primary  cancer,  which  formed 
a  tumor,  while  its  fellow  only  contained  small  secondary  nodules. 
In  the  60  unilateral  cases,  each  kidney  was  affected  an  equal 
number  of  times. 

The  primary  disease  in  the  kidney  was  associated  with  secon- 
dary deposits  elsewhere  in  31  out  of  51  cases  which  give  details 
on  this  point :  in  the  remaining  20  cases  all  other  parts  were 
exempt.  The  most  frequent  seats  of  secondary  deposits  w^ere 
the  lymphatic  glands  in  the  hilus  of  the  kidney,  and  the  verte- 
bral and  mesenteric  glands.  These  glands  formed  in  some  of 
the  cases  a  large  tumor,  which — as  in  a  case  to  be  presently  re- 
lated— transcended  the  dimensions  of  the  renal  tumor,  and 
greatly  embarrassed  the  diagnosis.  The  lungs  and  liver  were 
also  often  affected;  the  other  organs  more  rarely;  but  instances 
are  on  record  in  which  almost  every  conceivable  combination 
existed.  The  following  table  exhibits  the  distribution  of  the 
secondary  deposits  in  the  31  cases  already  alluded  to: 

1  In  Case  2,  reported  a  few  pages  further  on,  the  position  of  the  spleen  was 
exceptional ;  it  was  carried  downwards  toward  the  iliac  fossa  in  front  of  the 
tumor. 


518 


CANCEK    OF    THE    KIDNEY, 


Kidneys  alune  affected        .......     20  oases. 

Secondary  deposits  found  elsewhere  .         .         .         .         .     31     " 

Seat  of  secondary  deposits : 

Lumbar,  mesenteric  and  vertebral  glands          .         .         .  15  " 

Lungs          .         .         .         .         .         .         .         .         .         .  14  " 

Liver           .         . 14  " 

Suprarenal  capsules    .         ,         .         .         ...         .         .  4  " 

Omentum    ..........  3  " 

Heart 3  " 

Vertebrae  and  rib         ........  3  " 

Costal  surface  of  pleura      .         .         .         .         .         .         .  1  " 

Bladder,  uterus,  penis,  and  testicle — each           .         .         .  1  " 

The  infrequent  association  of  primary  renal  cancer  with  can- 
cerous deposits  in  the  lower  urinary  passages,  which  this  table 
shows,  is  somewhat  remarkable,  and  is  scarcely  what  one  would 
expect,  considering  the  close  anatomical  and  functional  relations 
of  these  parts.^ 

Etiology. — Renal  cancer  prevails  at  two  distinct  epochs  of 
life — in  early  childhood,  and  in  adult  age.  During  adolescence 
the  liability  to  it  sinks  to  a  minimum.  Children  under  five 
years  of  age  appear  especially  liable  to  renal  cancer :  22  out  of 
67  cases  occurred  at  this  early  period  ;  3  others  between  seven 
and  ten  years  :  the  remainder  were  distributed  pretty  equally 
between  the  ages  of  nineteen  and  seventy.  The  annexed  table 
shows  more  exactly  the  relation  of  age  to  the  frequency  of  renal 
cancer : 


25  children 


0-1 

1-2 

2-3 

3-5 

7-8 

10 

yr. 

yrs. 

yrs. 

yrs. 

yrs. 

yrs. 

2 

6 

6 

8 

2 

1 

19 

yrs. 

20-30 

yrs. 

30-40 
yrs. 

40-50 
yrs. 

50-60 
yrs. 

60-70 
yrs. 

Above 
70  yrs. 

36  adults^        .... 

1 

7 

5 

4 

9 

9 

1 

1  I  had  an  opportunity  of  examining  a  man  (set.  40)  who  died  at  the  Royal 
Infirmary  with  extensive  cancer  of  the  stomach,  combined  with  primary  cancer 
of  the  right  kidney.  The  latter  organ  was  wholly  converted  into  an  encephaloid 
mass.  I  could  not  detect  any  traces  of  secreting  structure  in  it :  the  mass  was 
somewhat  smaller  than  the  natural  kidney,  and  about  the  same  shape.  The  left 
kidney  was  quite  healthy,  and  greatly  hyperlrophied.  The  right  ureter  was  per- 
vious, but  shrunk  to  about  half  its  usual  size.  The  left  ureter  was  somewhat 
more  capacious  than  natural.  The  right  suprarenal  capsule  was  wholly  converted 
into  a  cancerous  mass.  There  was  very  extensive  cancerous  disease  (in  nodules) 
of  the  liver,  and  of  the  vertebral  glands. 

"  In  seven  adults  the  exact  age  is  not  ffiven. 


SYMPTOMS.  519 

The  male  sex  is  considerably  more  liable  to  renal  cancer  than 
the  female.  Sixty-six  cases,  in  which  the  sex  was  distinguished, 
supplied  47  males,  and  19  females.  The  jireponderance  of  the 
male  sex  is  not  so  great  in  childhood  as  in  adult  age.  Of  24 
children,  15  were  boys  and  9  girls;  of  42  adults,  32  were  men 
and  only  10  women.  The  great  disproportion  between  the 
frequency  of  renal  cancer  in  men  and  in  women  may  possibly 
be  explained  by  the  marked  preference  shown  by  cancer  for  the 
generative  organs  in  the  female. 

The  exciting  cause  of  renal,  as  of  other  cancers,  is  wrapped 
in  obscurity.  In  a  few  instances,  a  blow  or  fall  on  the  loins  was 
the  immediate  precursor  and  supposed  cause  of  the  first  symp- 
tom ;  but  the  disease  had  doubtless  already  been  in  existence 
before  the  accident,  though  concealed.  In  a  case  mentioned  by 
Manzolini  ("  Schmidt's  Jahrb.,"  B.  94,  S.  74),  a  boy  was  kicked  in 
the  left  side  ;  this  was  followed  by  hsematuria  for  fourteen  days. 
Shortly  after,  a  swelling  appeared  in  the  left  loin,  which  event- 
ually proved  to  be  an  encephaloid  growth  of  the  left  kidney. 

Symptoms  and  Physical  Signs. — The  distinctive  symptoms  of 
primary  cancer  of  the  kidney  are :  tumor  in  the  abdomen  and 
hcematuria.  In  every  case  in  which  the  disease  was  the  deter- 
mining cause  of  death,  one  or  both  of  these  symptoms  were 
present.^ 

Abdominal  tumor  is  by  far  the  most  constant  sign  of  renal 
cancer,  and  usually  the  earliest  one  noticed.  Out  of  64  cases 
there  were  only  3  in  which  a  distinct  intumescence  could  not  be 
felt  in  the  site  of  the  kidney  or  thereabouts ;  and  in  these  three 
there  was  hsematuria.  In  the  remaining  61  cases  a  tumor  was 
easily  ascertained  to  exist  in  the  abdomen  ;  and  in  all  but  three 
it  was  of  such  size  and  prominence  that  it  could  not  escape  the 
most  cursory  examination.  It  is  noteworthy  that  in  all  the 
children  a  large — nearly  always  an  enormous — tumor  existed. 

The  tumor  presents  itself  iirst  in  the  anterior  lumbar  region, 
between  the  margins  of  the  ribs  and  the  crista  ilii ;  it  then 
grows  forward  to  the  umbilicus,  upwards  into  the  hypochou- 
drium,  and  downwards  into  the  iliac  and  inguinal  regions:  in 
extreme  cases  it  fills  the  entire  belly.  The  tumor  may,  or  may 
not,  be  covered  with  a  ramification  of  enlarged  superficial 
veins.  The  colon,  and  sometimes  a  portion  of  the  small  intes- 
tines, lies  in  front  of  it.     This  position  of  the  colon  furnishes 

1  Lebert  states  that  he  has  known  an  instance  in  which  the  disease  ran  a  hitent 
course  throughout :  but  he  does  not  say  whether  in  that  instance  the  renal  disease 
was  really  the  cause  of  death.  In  a  case  of  primary  cancer  of  both  kidneys  re- 
ported by  Dr.  Fleming  to  the  Dublin  Pathological  Society  (Dub.  Quart.  .Journ., 
xliv.  235),  the  patient  stated  that  he  never  had  had  hajmaturia,  and  there  was  no 
tumor  traceable  in  the  abdomen. 


520  CANCER    OF    THE    KIDNEY. 

an  important  diagnostic  mark  of  all  renal  tumors.  Percussion 
over  the  tumor  is  dull,  except  where  the  colon  intervenes.' 

To.  the  hand  the  tumor  feels  smooth  or  irregularly  lobulated, 
with  rounded  obtuse  margins.  The  lobulations  are  often  of 
unequal  hardness,  and  a  deceptive  sense  of  fluctuation  may  be 
felt  in  places,  or  in  the  tumor  generally.  In  Langstaff's  case,  a 
distinct  and  persistent  pulsation  was  perceptible  in  the  tumor ; 
and  a  similar  phenomenon  was  noted  in  Bristowe's  case  ("  Med. 
Times  and  Gaz.,"  1854,  ii.  395).  The  fixity  of  the  growth  is 
usually  a  marked  characteristic.^ 

The  second  symptom  in  importance  is  hsematuria.  Details  on 
this  point  are  supplied  in  59  cases.  Of  these,  28  exhibited  no 
trace  of  hsematuria  throughout  their  entire  course.  In  31  cases 
there  was  hsematuria;  but  in  5  of  these,  there  existed  other 
possible  causes  for  it  than  renal  cancer  (calculi,  Bright's  disease, 
external  violence).  These  figures,  even  with  this  abatement,  do 
not  sufficiently  express  the  danger  of  relying  too  strongly  on 
hsematuria  as  a  sign  of  renal  cancer.  In  6  instances  hsematuria 
occurred  only  for  a  few  weeks  at  the  beginning  of  the  complaint, 
and  then  altogether  ceased — the  urine  thereafter  continuing 
normal.  In  one  case  there  was  hsematuria  for  a  short  period  at 
first,  and  none  during  the  remainingfour  years  of  life.  In  another 
case  (Case  1,  shortly  to  be  detailed)  hsematuria  was  present  for 
some  months,  and  at  once  disappeared  on  the  voiding  of  a  small 
calculus — it  did  not  recur  during  the  subsequent  five  years  of 
life.  In  other  cases  hsematuria  did  not  appear  until  toward  the 
last  few  moments  of  life — perhaps  years  after  the  detection  of  a 
tumor  in  the  loin.  The  absence  of  hsematuria  seems  to  depend 
generally  on  the  occlusion  of  the  ureter,  either  by  the  pressure 
of  the  tumor  or  the  extension  of  the  disease  into  it. 

^  This  position  of  the  colon  was  however  not  discovered  in  all  the  cases — gener- 
ally, no  doubt,  from  defective  examination  ;  but  in  some  cases  the  detection  of  the 
gut  may  prove  impossible,  from  its  being  compressed  between  the  tumor  and 
abdominal  wall,  and  emptied  of  flatus.  In  doubtful  cafes,  it  might  be  of  service 
to  inject  air  per  rectum,  in  order  to  inflate  the  collapsed  gut. 

The  following  remarks,  by  Bright,  deserve  to  be  borne  in  mind  in  searching  for 
tumors  of  the  kidney  :  "  In  those  diseases,"  he  says,  "  in  which  it  (the  kidney) 
most  rapidly  increases,  the  enlargement  shows  itself  much  more  towards  the 
anterior  part  of  the  abdomen  than  towards  the  loins,  not  only  because  the  firm 
structure  of  this  part  is  more  calculated  to  conceal  a  tumor,  but  also  because,  in 
the  other  direction,  it  meets  with  less  immediate  resistance  ;  so  that  it  often  hap- 
pens, while  we  are  examining  the  lumbar  region  with  the  greatest  care,  and  ob- 
taining but  a  doubtful  evidence  of  fulness  and  hardness  by  the  eye  and  by  the 
touch,  and  by  a  careful  comparison  of  the  two  sides,  we  can  scarcely  place  the 
hand  upon  the  anterior  or  even  the  lateral  part  without  becoming  at  once  sensible 
of  the  existence  of  a  distinct  tumor  ;  and  then,  probably,  by  pressing  that  tumor 
backward,  the  other  hand  clearly  informs  us  of  its  connection  with  the  loins." 
(Loc.  cit.,  199.) 

^  In  the  Lancet  for  March  18,  1865,  is  an  account  of  a  case  of  movable  kidney 
affected  with  malignant  disease.  The  tumor  was  mistaken  for  an  ovarian  growth, 
and  operation  for  its  removal  commenced.    The  intestines  were  all  behind  the  tumor. 


SYMPTOMS.  521 

When  hEeraaturia  is  present,  it  is  a  sign  of  very  great  value, 
'  and  its  character  and  features  deserve  attentive  study.  As  a 
rule,  it  is  irregularly  intermittent  and  profuse.  It  recurs  at 
intervals  of  a  few  days  or  weeks,  usually  without  any  ai»[)recia- 
ble  cause.  The  tumor  is  not,  of  course,  insensible  to  external 
violence :  and  in  more  than  one  instance  a  blow  or  fall  on  the 
loin  has  been  the  immediate  precursor  of  the  appearance  of  blood 
in  the  urine.  In  some  cases  the  hemorrhage  is  excessive,  and 
followed  by  rapid  ansemia  and  exhaustion,  though  this  is  rare. 
Generally  the  loss  of  blood  is  moderate,  sometimes  insignificar)t, 
and  requiring  the  microscope  for  its  detection.  The  tormation 
of  clots  in  the  bladder,  and  their  impaction  in  the  urethra,  is 
sometimes  a  source  of  severe  suffering,  and  occasions  excessive 
irritability  of  the  bladder. 

Other  changes  in  the  composition  of  the  urine  are  sometimes 
found,  but  they  are  not  distinctive.  Of  course,  albumen  always 
exists  in  the  urine  when  it  contains  blood  ;  more  rarely  albu- 
minuria occurs  independently  of  h?ematuria,  from  genuine 
Bright's  disease  affecting  either  the  exempted  portions  of  the 
cancerous  kidney,  or  the  opposite  organ.  Not  unfrequently, 
epithelial  cells  from  the  pelvis  of  the  kidney  and  ureter  are 
found  in  the  urine,  mixed  with  the  blood. 

The  presence  of  cancer  cells  in  the  urine  is  a  sign  which  usuall}^ 
figures  prominently  in  the  catalogue  of  symptoms  of  renal  cancer, 
but  its  value  is  very  doubtful.  In  all  the  later  cases,  especially 
where  there  was  hsematuria,  the  urine  was  carefully  examined 
for  cancer  cells,  but  without  success.  Rosenstein  mentions  a 
case  in  which  a  cancerous  villus  was  actually  found  projecting 
into  the  ureter,  yet  no  cancer  cells  could  be  detected  in  the  urine 
during  life.  It  is  by  no  means  an  easy  matter  to  identify  cancer 
cells  in  the  urine,  in  consequence  of  their  similarity  to  the  tran- 
sitional epithelium  of  the  pelvis  and  ureter.  It  must  be  further 
remembered,  that  any  cancer  cells  which  could  find  their  way 
into  the  urine,  must  have  escaped  from  parts  of  the  growth  which 
were  broken  dow^n  and  degenerated;  and  to  identify  character- 
istic forms,  in  the  ichorous  detritus  even  of  an  external  cancer, 
is  more  than  I  have  ever  succeeded  in  accomplishing :  how  much 
greater  the  difficulty,  when  that  detritus  has  been  further  disin- 
tegrated by  the  action  of  the  urine  !  In  two  examples  of  renal 
cancer,  with  hsematuria,  wdiich  I  have  had  an  opportunity  of 
observing,  repeated  and  careful  examination  of  the  urine  failed 
to  discover  the  presence  of  cancer  cells  or  of  cells  which  might 
be  mistaken  for  them.^ 

'  Mr.  Moore  believes  that  lie  succeeded  in  identifving  cancer  cells  in  the  urine 
drawn  after  death  from  the  bladder  of  a  man  in  whose  kidneys  cancerous  nodules 
were  found  ;  but  his  description  rather  accords  with  the  appearances  of  the  epithe- 
lial cells  which  are  alwaj^s  freely  detached  from  the  vesical  mucous  membrane 
after  death.     (Med.-Chir.  Trans.,  xxxv.  4G6.) 


522  '         CANCER    OF    THE    KIDNEY. 

The  other  symptoms  which  have  been  noted  in  cases  of  renal 
cancer  are  less  distinctive  and  constant  than  tumor  in  the  abdo- 
men and  hsematuria.  The  most  important  is  pain  in  the  hypo- 
chondriumand  loin.  This  is  sometimes  an  early  symptom,  and 
may  show  considerable  severity.  The  pain  is  commonl}^  inter- 
mittent; it  shoots  down  in  the  course  of  the  ureter  to  the  inside 
of  the  thighs.  It  does  not  appear  to  be  ever  associated  with  re- 
traction of  the  testicle.  Pain  is,  however,  wholly  absent  for 
long  periods  in  a  large  number  of  eases :  the  tumor  itself  may 
be  perfectly  painless  on  handling,  and  give  no  inconvenience 
except  from  its  weight  and  size. 

Gastric  symptoms — nausea,  vomiting,  anorexia, — are  com- 
mon, and  in  several  cases  they  were  noted  among  the  earliest 
symptoms.  In  other  cases,  again,  none  of  these  existed  :  the 
appetite  was  excellent;  in  five  cases  (all  children)  it  was  even 
voracious. 

The  general  health  varied  exceedingly.  In  the  majority  of 
cases,  rapid  emaciation  took  place,  going  on  at  length  to  an 
extreme  degree,  with  failing  strength,  and  yellowish  discolora- 
tion of  the  skin.  In  other  cases,  many  months,  or  even  years 
(in  adults),  passed  over  after  the  detection  of  the  tumor,  before 
the  health  seriously  gave  way. 

The  cancerous  tint  is  not  often  mentioned  in  the  list  of 
S3'mptoms,  but  this  may  have  been  from  the  brevity  of  many  of 
the  reports. 

The  bowels  are  generally  disordered  when  the  tumor  attains 
a  large  size ;  diarrhoea,  or  obstinate  constipation  prevails ;  or 
the  two  conditions  alternate. 

Towards  the  later  periods,  anasarca  of  the  legs  often  sets  in, 
and  it  may  even  extend  over  the  whole  body.  Signs  of  consti- 
tutional irritation  also  present  themselves,  and  become  per- 
sistent. Life  is  at  length  worn  out  by  gradual  exhaustion  of 
the  vital  powers  :  sometimes  death  is  more  suddenl}^  induced  by 
rupture  of  the  tumor. 

When  there  is  no  hsematuria  the  urine  is  commonly  normal ; 
the  healthy  kidney  becomes  hypertrophied,  and  performs  double 
duties.     In  no  instance  did  ursemic  symptoms  arise. 

The  duration  of  the  disease  from  the  first  appearance  of  symp- 
toms to  the  fatal  termination  varied  exceedingly.  The  duration 
was  much  shorter,  as  might  have  been  anticipated,  in  children 
than  in  adults.  Among  the  former,  19  cases  are  available  for 
comparison  :  the  mean  duration  was  nearly  seven  months;  the 
minimum  was  ten  weeks,  and  the  maximum  "  over  a  year."  In 
adults  (21  cases  available)  the  disease  continued  on  an  average 
two  and  a  half  years ;  the  extremes  ranged  from  five  months  to 
seven  years;  8  died  under  the  twelvemonth,  7  under  three  years, 
2  survived  four  years,  3  six  years,  and  1  seven  years. 


ILLUSTRATIVE    GASES.  52;} 

These  numbers,  as  well  as  those  having  reference  to  the  age 
of  the  patients,  disagree  with  the  statements  currer)t  in  hooks; 
and  some  of  the  numerous  errors  in  the  diagnosis  of  renal 
cancer  may  be  traced  to  mistaken  impressions  as  to  the  prevail- 
ing age  and  survivorship  of  patients  so  aliected.  The  supposi- 
tion of  Walshe,  endorsed  by  Lebert,  that  cancer  of  the  kidney 
runs  a  more  rapid  course  than  other  internal  cancers,  is  not  only 
unsupported  by  these  large  numbers,  but  the  contrary  is  clearly 
established,  namely,  that,  as  a  rule,  death  is  longer  delayed  in 
renal  cancer  than  in  primary  cancer  of  any  other  internal  organ.' 
The  reason  of  this  tolerance  must  be  looked  for  in  the  duplica- 
tion of  the  organ,  the  facility  with  which  one  kidney  undergoes 
a  compensating  hypertrophy  when  its  fellow  is  disabled,  and 
takes  upon  it  the  work  of  the  pair ;  also  the  free  room  for 
enlargement  which  is  atforded  in  the  lumbar  region,  and  the 
comparatively  innocuous  effects  of  displacement  on  the  abdomi- 
nal organs.^ 

The  following  examples  will  serve  to  illustrate  the  chief 
features  of  the  disease. 

Case  1.  Encephaloid  cancer  of  the  left  kidney;  secondary  cancer  of  left 
pleura. — Mr.  E.,  set.  70,  was  visited  by  me  with  Mr.  Jonathan  Wilson, 
in  March,  1868.  He  was  suffering  from  an  enormous  tumor  in  the  left 
flank.  It  appears  that  five  years  ago  he  suffered  from  profuse  and  re- 
peated hsematuria.  After  some  months  he  voided  a  small  calculus,  and 
then  the  symptoms  disappeared.  He  continued  in  good  health  for  five 
years,  and  then  came  under  treatment  again  for  shortness  of  breath  and 
general  debility.  Being  somewhat  fat  and  ventricose,  he  had  not  become 
aware  himself  of  any  tumor  in  the  side;  but  when  the  abdomen  was 
examined,  a  very  large  solid  growth  was  discovered,  filling  the  entire  of 
the  left  half  of  the  belly.  How  long  this  had  been  growing  there  was 
no  evidence  to  show.  The  tumor  occupied  the  left  hypochondriac  and 
lumbar  regions,  reaching  forwards  to  the  umbilicus  and  downwards 
almost  to  the  crest  of  the  ilium.  Its  front  boundary  had  a  rounded  out- 
line ;  its  surface  was  wholly  dull  on  percussion,  even  as  far  back  as  the 
spine;  no  bowel  could  be  perceived  in  front  of  it.  It  felt  hard,  rigid, 
and  perfectly  fixed  in  its  position.  There  was  a  moderate  amount  of 
ascites,  with  pleuritic  eflTusion  on  the  left  side  as  high  as  the  third  rib; 
the  other  organs  were  healthy. 

'  The  mean  duration  of  cancer  of  the  pylorus,  according  to  the  combined  statis- 
tics of  Lebert,  Herrich  and  Popp,  and  Valleix,  is  under  a  year  :  out  of  71  cases, 
48  died  within  the  year,  and  ahiiost  all  the  remainder  (23  cases)  within  Uv6  years. 
The  majority  of  hepatic  cancers  terminate  probably  under  eight  months  — certainly 
under  a  year  (see  Kohler,  pp  308,  37(J).  Walshe  estimates  the  mean  duration  of 
cancer  of  the  lungs  at  13.2  months  (loc.  cit.,  p  348) ;  and  he  thinks  cancer  of  the 
brain  rarely  lasts  over  a  year.     (Ibid.,  p.  496.) 

2  Three  exceptional  cases  of  cancer  of  the  kidney,  which  apparently  lasted 
respectively  12,  14,  and  16  years,  will  be  found  in  the  Lancet,  1877,  i.  p.  194, 
and  p.  567.  It  must  be  remembered  in  connection  with  such  cases  that  a  benign 
tumor  may  exist  for  some  time  and  then  undergo  transformation  into  a  malignant 
growth. 


524  CANCER    OF    THE    KIDNEY. 

The  general  condition  was  greatly  depressed,  the  countenance  sallow, 
the  appetite  almost  lost.  He  lay  continuously  on  his  left  side,  and  com- 
plained of  great  and  constant  pain  in  the  left  loin.  There  was  no 
oedema  of  the  feet  or  hands.  The  urine  was  scanty,  high-colored,  and 
charged  with  lithates ;  but  there  was  no  albumen  or  blood,  nor  had  there 
been  any  for  the  last  five  years. 

The  patient  was  heavy  and  unwieldy,  and  unable  to  turn  himself  in 
bed ;  bed-sores  formed,  and  he  gradually  sank  from  exhaustion,  after 
having  been  under  observation  for  a  month. 

Autopsy. — When  the  abdomen  was  opened,  the  tumor  was  found  to  be 
the  left  kidney,  wholly  changed  into  an  enormous  encephaloid  mass.  It 
was  twelve  inches  long,  eight  broad,  and  five  thick ;  it  had  an  ovoid 
shape,  and  weighed  eleven  pounds.  Its  surface  was  smooth,  and  covered 
with  a  tough  investment  of  fibrous  tissue.  In  front  of  the  tumor  ran 
the  descending  colon,  which  was  not  adherent,  but  perfectly  empty,  and 
contracted  to  the  size  of  the  finger.  On  cutting  open  the  tumor,  it  was 
found  to  consist  of  firm,  yellowish-white,  encephaloid  matter,  scattered 
through  which  were  several  masses  of  soft,  clotted  blood.  There  was 
no  vestige  of  renal  tissue.  The  ureter  was  healthy,  but  occluded  by  the 
pressure  of  the  growth.  The  renal  vessels  were  also  healthy.  The 
spleen  was  pushed  up  into  the  vault  of  the  diaphragm,  and  lay  above 
the  tumor.  The  left  pleura  contained  a  large  amount  of  sanguinolent 
fluid ;  on  its  costal  surface  were  several  cancerous  nodules,  as  large  as 
filberts.  The  other  organs  were  healthy.  The  right  kidney  weighed 
seven  and  a  half  ounces,  and  was  quite  free  from  cancer.  No  calculous 
concretion  was  found  in  either  kidney. 

Case  2.  Encephaloid  cancer  of  the  left  kidney ;  unusual  position  •  of 
spleen  and  pancreas;  calculi  in  the  right  kidney. — F.  M.,  a  toy-dealer, 
aged  44,  residing  at  Northwich,  was  admitted  into  the  Manchester  In- 
firmary in  March,  1868.  His  illness  began  two  years  and  a  half  ago 
with  slight  and  temporary  hsematuria.  Fourteen  months  ago  more 
violent  ha3maturia  took  place,  which  has  continued  more  or  less  ever 
since.  His  medical  attendant  discovered  a  lump  in  the  left  side  a 
twelvemonth  ago,  and  since  then  he  has  gradually  become  weaker  and 
thinner,  and  the  lump,  has  steadily  increased  in  size. 

On  admission  he  was  extremely  emaciated,  countenance  of  a  greenish 
sallow  appearance,  drawn  and  suggestive  of  suflfering ;  tongue  red  and 
dryish  ;  p.  94,  r.  24.  No  oedema  of  any  part.  The  abdomen  was  much 
enlarged,  especially  on  the  left  side,  and  on  palpation  a  large  solid 
tumor,  as  large  as  a  man's  head,  was  felt  on  the  left  side  of  the  abdomen, 
occupying  the  epigastric,  hypochondriac,  and  lumbar  regions.  The  limits 
of  the  tumor,  as  ascertained  by  palpation  and  percussion,  were  as  fol- 
lows (see  Fig.  QQ).  The  anterior  margin  could  be  traced  from  a  little 
to  the  right  of  the  ensiform  cartilage,  running  downwards  an  inch  and 
a  half  to  the  right  of  the  middle  line.  About  an  inch  above  the  um- 
bilicus, the  outline  twined  abruptly  to  the  left,  crossed  the  middle  line, 
and  then  descended  obliquely  into  the  iliac  fossa,  as  low  as  the  crest  of 
the  ilium.  Upwards,  the  growth  extended  beneath  the  ribs,  bulging 
these  out,  almost  as  high  as  the  nipple.  Posteriorly,  the  growth  occu- 
pied the  whole  lumbar  region,  and  caused  a  marked  fulness  in  the  site 


ILLUSTRATIVE    CASES, 


525 


of  the  kidney.  The  area  of  the  tumor  was  dull  on  percussion,  except 
in  the  epigastrium,  and  along  the  left  costal  margin,  where  a  tympanitic 
note  indicated  that  the  stomach  lay  in  front  of  it.  The  descending 
colon  could  easily  be  traced  in  front  of  the  tumor — it  was  often  loaded 
with  masses  of  scybala.  Over  the  lower  part  of  the  tumor,  in  the  iliac 
fossa,  there  lay  a  detached  portion,  resembling,  both  in  shape  and  in 

Fig.  m. 


Diasram  showing  the  position  and  relation  of  tlie  tumor  in  the  ease  of  F.  31  : 
g,  stomacli ;  c,  colon  ;  s,  spleen. 

feeling,  a  somewhat  enlarged  spleen ;  this  portion  was  freely  movable 
upon  the  main  tumor,  and  had  no  intestine  in  front  of  it.  The  upper 
part  of  the  tumor  in  the  epigastrium  had  a  nodular  tuberous  feel,  and 
was  covered  by  bowel.  Along  the  costal  margin  a  large  artery  could  be 
felt  pulsating  on  the  surface  of  the  tumor ;  this  artery  communicated  a 
distinct  thrill  to  the  finger,  and  was  the  seat  of  a  loudish  systolic  mur- 
mur. The  general  surface  of  the  tumor  was  smooth  and  tensely  elastic 
— not  fluctuating,  but  different  parts  varied  sensibly  in  their  degree  of 
softness  and  hardness.  The  growth  was  immovably  fixed  in  its  position, 
and  meandering  veins  coursed  over  the  skin,  covering  its  outer  and  more 
prominent  portions.  There  was  also  an  abundant  varicocele  on  the  left  ■ 
side,  and  the  veins  of  the  penis  were  very  large  and  tortuous. 

The  urine  contained  blood,  partly  in  small,  round,  or  filamentous 
clots,  and  partly  mingled  with  the  urine.  There  were  no  casts,  and  the 
quantity  of  albumen  was  not  greater  than  the  blood  accounted  for. 

The  organs  ijj  the  chest  were  healthy,  but  they  were  considerably  dis- 


526  CANCER    OF    THE    KIDNEY. 

placed  upwards  by  the  pressure  of  the  abdominal  tumor.  The  heart's 
apex  beat  in  the  fourth  interspace,  and  the  cardiac  dulness  mounted  as 
high  as  the  second  rib.  The  liver  was  also  pushed  upwards;  its  upper 
margin  corresponding  with  the  fifth  rib  in  the  vertical  line  of  the  nip- 
ple. The  patient  complained  of  a  good  deal  of  pain  of  a  gnawing  char- 
acter in  the  left  loin  and  in  the  groin. 

The  patient  remained  in  the  Infirmary  for  six  weeks.  During  this 
period  the  physical  signs  underwent  no  marked  change ;  the  tumor 
slowly  enlarged,  and  the  strength  and  flesh  continued  to  decline.  The 
urine  always  contained  more  or  less  blood,  but  the  quantity  was  never 
really  large,  and  very  often  it  required  the  microscope  to  detect  it.  It 
was  noticed  that  there  was  generally  more  blood  in  the  urine  after  pro- 
longed manipulation  of  the  tumor.  The  bowels  were  exceedingly  torpid, 
and  required  the  frequent  use  of  enemata  for  their  relief.  Beyond  the 
use  of  these  and  of  anodynes  to  procure  sleep  and  allay  the  pain,  no 
remedial  means  were  attempted. 

After  leaving  the  Infirmary,  he  returned  to  Northwich,  and  placed 
himself  under  the  care  of  Mr.  Williams,  of  that  town.  He  continued 
to  sink  very  gradually  as  the  tumor  enlarged,  and  died  on  October  8th 
— five  months  after  his  discharge  from  the  hospital,  eighteen  months 
after  the  first  discovery  of  the  tumor,  and  three  years  after  the  first 
appearance  of  hi«maturia. 

Careful  inquiries  respecting  the  hsematuria  elicited  the  following  par- 
ticulars :  Blood  first  appeared  in  the  urine  three  years  before  death. 
For  three  weeks  at  that  time  pure  blood  was  repeatedly  voided  ;  then 
for  a  period  of  twelve  months  no  more  blood  was  seen.  Again  about  a 
pint  of  blood  was  voided,  and  after  this  it  continued  in  greater  or  less 
quantity  until  his  death.  The  blood  was  nearly  always  more  or  less 
clotted. 

I  went  over  to  Northwich  to  make  the  autopsy  with  Mr.  Williams. 
The  emaciation  had  reached  the  most  extreme  degree  compatible  with 
life ;  the  muscular  tissue  had  almost  vanished.  Our  astonishment  was 
great  to  find  the  abdomen  sunk  so  as  scarcely  to  constitute  a  notable 
tumor.  This  had  arisen  apparently  from  the  oozing  out  of  the  tumor 
of  a  considerable  quantity  of  a  bloody  fluid,  which  we  found  in  the  peri- 
toneal cavity.  When  the  belly  was  opened,  we  found  a  large  subglobular 
mass,  occupying  the  whole  of  the  left  side.  This  proved  to  be  the  left 
-kidney,  converted  into  a  mass  of  soft  cancer.  Overlapping  its  upper 
end  was  the  empty  stomach,  and  along  the  great  curvature  of  this  viscus 
coursed,  with  very  tortuous  windings,  an  artery  as  large  as  the  radial 
(right  gastro-epiploic).  This  was  evidently  the  source  of  the  pulsation 
felt  during  life  at  the  costal  margin.  Riding  freely  on  the  lower  and 
inner  (or  right)  border  of  the  tumor  and  the  adjacent  portions,  lay  the 
spleen,  forming  a  flattened  oval  cake,  7  inches  long  by  4  inches  wide. 
This  was  the  movable  spleen-like  body  felt  during  life  near  the  iliac  fossa. 
Between  it  and  the  stomach  stretched  the  transparent  layers  of  the  gas- 
tro-splenic  omentum.  The  colon,  contracted  and  empty,  passed  in  front 
of  the  inner  portion  of  the  tumor,  under  the  spleen,  and  again  in  front 
of  the  lower  part  of  the  tumor,  crossing  it  obliquely  near  its  right  mar- 
gin.    The  body  and  tail  of  the  pancreas  ran  horizontally  right  across  the 


ILLUSTRATIVE    CASES.  527 

tumor,  midway  between  the  border  of  the  stomach  and  the  sjjieen,  behind 
the  folds  of  the  gastro-splenic  omentum. 

The  tumor  constituted  u  somewhat  flattened  and  elongated  sphere,  in 
parts  with  a  lobular  or  tuberculated  surface,  and  in  part  smooth.  It 
occupied  the  entire  vault  of  the  diaphragm  (jn  the  left  side,  the  epigas- 
trium, and  the  left  lumbar  region  as  low  as  the  crest  of  the  ilium.  It 
was  immovably  fixed  here,  and  adherent  to  the  diaphragm  and  to  the 
soft  parts  of  the  loin.  The  spleen  and  stomach  were  not  adherent;  the 
pancreas  and  omentum  were  loosely  adherent.  The  tumor,  in  the  epi- 
gastrium, extended  two  inches  beyond  the  middle  line,  pushing  aside 
the  liver  and  pressing  on  the  vena  cava  and  its  branches.  Some  of  the 
mesenteric  veins  were  also  compressed  and  enormously  distended  ;  the 
varicocele  was  quite  effaced  after  death.  The  tumor  weighed  six  pounds. 
At  its  lower  part  the  vestiges  of  the  kidney  could  be  recognized — still 
preserving  the  outline  of  the  gland.  The  ureter,  somewhat  smaller  and 
more  transparent  than  natural,  but  still  pervious,  could  be  traced  into 
the  remains  of  the  pelvis.  On  dividing  the  tumor,  the  mass  was  found 
to  consist  of  a  soft  cellular  encephaloid  matter,  deeply  infiltrated  in 
parts  with  blood.  The  scanty  remnants  of  the  kidney,  in  the  form  of  a 
thin  layer  of  indurated  cortical  substance,  was  stretched  over  the  lower 
part  of  the  tumor.  The  pelvis  consisted  of  three  or  four  communicating 
loculi,  filled  with  a  yellowish,  gelatinous  material. 

The  right  kidney  was  of  its  usual  dimensions,  and  its  substance  healthy ; 
but  the  infundibula  were  dilated,  and  contained  eight  phosphatic  calculi, 
varying  from  the  size  of  a  horse-bean  to  that  of  a  hempseed,  together 
with  a  multitude  of  smaller  granules  of  the  same  nature.  All  the  other 
organs  of  the  body  were  healthy,  and  there  were  no  secondary  can- 
cerous deposits  anywhere. 

The  positions  of  the  spleen  and  pancreas  were  quite  excep- 
tional in  this  case.  The  spleen  is  usually  carried  up  above  the 
tumor  into  the  vault  of  the  diaphragm:  here  it  la}'  in  front, 
and  was  pushed  downwards  into  the  iliac  fossa.  The  pancreas 
is  generally  left  undisturbed  in  its  normal  situation ;  but  in  this 
case  it  was  stretched  in  front  of  the  tumor.  Both  these  condi- 
tions were  probably  due  to  the  morbid  growth  having  com- 
menced at  the  upper  end  of  the  kidney. 

It  is  almost  certain  that  the  hsematuria  in  this  case  was  not 
altogether  derived  from  the  left  (or  cancerous)  kidney.  The 
earlier  and  more  profuse  bleedings  were  in  all  probability  so 
derived  ;  but  the  scantier  hemorrhage  of  the  later  periods  could 
not  have  had  this  source,  because  the  pelvis  of  the  left  ki.dney 
when  examined  after  death  only  contained  a  clear  yellow  fluid, 
and  the  secreting  substance  of  the  organ  was  completely  de- 
stroyed. The  scantier  but  more  constant  haematuria,  from  which 
the  patient  suffered  while  in  the  Infirmary,  was,  doubtless,  de- 
rived from  the  right  kidney,  in  the  infundibula  of  which  a 
number  of  calculous  concretions  were  found  after  death.  In 
further  evidence  of  this  it  should  be  mentioned,  that  the  urine-, 


528  CANCER    OF    THE    KIDNEY. 

while  the  man  was  under  observation,  always  contained  small 
calcareous  particles  composed  of  phosphate  of  lime — exactly 
similar  in  composition  to  those  found  in  the  kidneys  at  the 
autopsy.    • 

A  typical  example  of  infantile  renal  cancer  was  shown  to  me 
by  Dr.  Lloyd  Roberts.     The  following  are  his  notes  of  the  case : 

Case  3. — W.  A.  McE.,  aged  six  months,  was  sent  to  me  by  Dr.  Cran, 
of  Salford,  on  May  1,  1871,  suffering  from  abdominal  tumor.  The 
mother  stated  that  at  the  child's  birth  the  nurse  thought  he  had  a  "full 
stomach."  When  a  fortnight  old  he  suffered  from  a  severe  attack  of 
abdominal  pain  and  flatulency,  requiring  the  attendance  of  Dr.  Cran. 
After  this  he  remained  pretty  well  until  the  age  of  three  months,  when 
it  was  observed  that  his  abdomen  ^yas  larger  than  it  ought  to  be ;  and  it 
continued  from  this  time  to  enlarge.  The  child  was  subject  to  frequent 
attacks  of  diarrhoea  during  the  earlier  months  of  his  life,  the  stools 
appearing  like  "  boiled  moist  cabbage ;"  but  latterly  four  or  five  days 
would  elapse  without  any  evacuation,  the  motions  being  dry,  hard,  and 
yellow.  Up  till  the  time  of  death  he  passed  water  freely ;  it  was  always 
clear  and  free  from  blood.  The  appetite  was  voracious,  but  he  never 
seemed  to  rest  until  he  had  vomited  his  food.  He  suffered  much  from 
thirst. 

On  the  first  of  May  the  following  was  his  condition :  He  was  much 
emaciated.  The  veins  of  the  abdominal  wall  were  much  distended.  The 
abdomen  measured  21  inches  over  the  umbilicus,  and  was  almost  entirely 
filled  by  an  immovable  tumor  of  somewhat  irregular  shape.  There  was 
universal  dulness  over  the  abdomen,  with  the  exception  of  the  left  hypo- 
chondriac and  hypogastric  regions,  where  a  clear  bowel-sound  was  elicited 
on  percussion.  On  the  7th  of  July,  the  abdomen  measured  24  inches, 
having  increased  three  inches  in  a  little  over  two  months.  The  child 
died  on  14th  July. 

At  the  autopsy,  the  liver  was  found  thin  and  stretched  over  the  surface 
of  a  large  tumor,  which  was  found  occupying  the  entire  abdomen,  except 
the  left  inguinal  region,  into  which  the  intestines  had  been  pushed. 
There  was  no  fluid  in  the  peritoneal  cavity.  The  liver,  which  was  pale, 
but  seemed  otherwise  healthy,  was  connected  with  the  tumor  by  loose 
cellular  adhesions,  which  were  easily  separable  by  the  fingers,  so  that 
the  entire  tumor  was  removed  without  the  aid  of  a  knife.  It  was  found 
to  be  a  tumor  of  the  right  kidney,  and  weighed  5?  lbs.  The  growth  was 
irregularly  kidney-shaped,  and  traces  of  renal  structure  were  detected 
at  its  posterior  part.  On  section,  it  was  found  chiefly  composed  of  soft, 
brain-like  structure,  with  several  large  cysts  containing  fluid,  which  on 
microscopic  examination  was  seen  to  be  crowded  with  caudate  and  poly- 
gonal cells.  The  same  bodies,  in  a  fibrousdooking  stroma,  were  detected 
in  the  solid  portions  of  the  tumor.  The  left  kidney  was  rather  larger 
than  usual,  but  was  healthy  in  structure.  No  cancerous  deposit  was 
found  in  any  of  the  other  viscera. 

Case  4.  Primary  cancer  of  the  right  kidney,  and  of  the  lymphatic 
glands  in  the  hilus.  Secondary  cancer  of  the  liver,  left  lung,  and  supra- 
renal capstde  (from  the  notes  of  Dr.  Renaud). — Hannah  Hilton,  set.  59, 


ILLUSTRATIVE    CASKS.  529 

a  married  woman,  who  had  borne  children,  the  last  from  eight  to  nine 
years  ago,  ceased  to  menstruate  six  years  ago. 

She  first  noticed  a  small  and  hard  tumor  in  the  right  iliac  space  two 
years  since,  which  made  very  little  progress,  and  gave  no  pain  or  incon- 
venience for  many  mouths.  She  came  under  treatment  in  the  early 
part  of  December,  1845,  for  a  chronic  diarrh(x;a,  which  had  for  some 
time  past  baffled  all  remedies.  The  evacuations  were  most  copious,  of 
a  dirty  olive  color,  passed  without  pain  or  accompanied  with  tormina. 
This  ultimately  yielded  to  the  sulphate  of  copper. 

I  first  examined  the  tumor  about  twelve  months  ago.  It  was  painless, 
hard,  and  not  bigger  than  a  footal  head,  rising  a  little  out  of  the  right 
pelvic  region.  About  a  month  from  this,  the  tumor  began  to  be  painful 
and  to  increase.  A  feeling  of  crumpling  parchment  was  noticed  at  its 
inner  and  lower  portion.  Shortly  afterwards  it  began  to  extend  upwards 
and  backwards,  in  the  direction  of  the  loin  ;  there  were  flying  pains  also. 
The  uterus,  examined  manually,  was  found  free  from  the  tumor,  and 
apparently  healthy.  The  color  of  the  skin  was  somewhat  dirty,  and 
this,  together  with  the  crumpling,  were  thought  sufficiently  suspicious 
to  warrant  a  belief  that  the  real  nature  of  the  disease  was  malignant 
degeneration  of  the  right  ovary. 

I  now  lost  sight  of  the  case  until  three  weeks  prior  to  death,  when  I 
discovered  that  the  tumor  had  gradually  extended  itself  backwards,  and 
that  four  weeks  ago  it  began  rapidly  to  grow,  and  spread  in  all  direc- 
tions, causing  great  pain  and  watchfulness.  The  woman  emaciated  very 
fast,  was  of  a  deep  and  dirty-brown  color,  had  sunken  eyes,  and  a  look 
of  suffering.  The  nature  of  the  disease  remained  no  longer  doubtful, 
for  the  nodular  portions  of  the  fungus  hsematodes  could  be  most  dis- 
tinctly felt  beneath  the  abdominal  walls.  The  feeling  of  crumpling  was 
also  more  general,  as  also  an  occasional  gurgling  as  of  air,  in  the  intes- 
tines. There  had  been  no  uterine  hemorrhage,  no  difficulty  or  pain  in 
passing  urine,  and  nothing  unusual  in  the  character  of  the  secretion. 
Opiates  relieved  the  pain  greatly.     She  died  on  February  17,  1847, 

Autopsy. — Body  greatly  emaciated.  In  the  abdomen  there  was  a  large 
fungoid  tumor,  extending  quite  across  and  to  the  right  side  and  loins ; 
passing  obliquely  over  it  was  the  colon,  which  was  partially  adherent,  as 
were  also  some  of  the  small  intestinal  folds.  The  tumor  was  not  at  all 
adherent  to  the  interior  of  the  abdominal  walls.  The  uterus  and  ovaries 
were  quite  free  from  any  disease,  and  were  merely  bound  together  with 
false  membranous  bands.  The  tumor  had  no  pedicle,  and  though  most 
carefully  removed  there  were  no  connections  found  other  than  such  as 
had  been  set  up  through  peritoneal  irritation.  The  abdominal  cavity 
did  not  contain  any  dropsical  effusion.  The  entire  mass  being  removed, 
together  with  the  liver,  to  which  it  was  adherent,  the  right  kidney  was 
found  so  entirely  degenerated  into  encephaloid  matter,  and  so  closely 
incorporated  with  the  tumor,  that  nothing  but  a  most  careful  dissection 
could  have  detected  its  true  nature.  It  was  enlarged  to  double  its  usual 
size,  and  no  vestige  of  its  proper  structure  remained  ;  the  vessels  were, 
however,  found  entering  the  hilus  ;  and  the  suprarenal  capsule,  also 
affected  with  encephaloid  cancer,  was  in  its  usual  position,  and,  in  size 
and  shape,  bore  a  resemblance  to  a  very  large  chestnut. 

In  the  large  tumor,  which  appeared  to  have  its  origin  in  the  lymphatic 

34 


630  CANCER    OF    THE    KIDNEY. 

glands  of  the  hilus,  were  some  cysts,  filled  with  a  grumous  matter  or 
with  a  semi-transparent  jelly-like  substance.  The  great  mass  was  a 
homogeneous  and  soft  cancer,  breaking  down  in  most  parts,  but  in  some 
places  as  hard  as  cheese.  The  tumor  was  rounded,  and  about  four 
inches  thick,  where  it  lay  in  the  loin  on  the  right  side,  and  gradually 
became  more  thin  toward  the  left  margin,  where  it  dipped  beneath  the 
stomach,  surrounding  the  aorta  and  vena  cava,  in  one  portion  of  which 
cancerous  matter  was  found.  The  extreme  breadth  of  the  tumor  was 
nine  inches. 

The  lower  margin  of  the  liver  was  cancerous  where  the  tumor  came 
in  contact  with  it,  and  some  other  small  cancerous  tubera  were  found  on 
its  surface.  The  gall-bladder  contained  many  calculi.  On  the  surface 
of  the  lower  lobe  of  the  left  lung  were  several  tubera,  and  one  as  large 
as  a  small  apple.  The  heart,  left  kidney,  spleen,  right  lung,  and  other 
parts  were  healthy,  and  free  from  all  traces  of  disease. 

Dr.  Hounsell  has  kindly  furnished  me  w^ith  the  notes  of  the 
following  hitherto  unpublished  case.  It  illustrates  the  usual 
features  of  the  disease  as  it  appears  in  children. 

Case  5.  Encephaloid  disease  of  the  right  kidney  in  a  child  (from  the 
notes  of  Dr.  Hounsell,  of  Torquay). — Richard  Bradford,  four  years  of 
age,  was  admitted  as  out-patient  of  the  Torbay  Infirmary  about  ten  days 
before  his  death.  He  was  suffering  from  a  large  tumor  occupying  the 
umbilical,  right  hypochondriac,  and  lumbar  regions.  Its  surface  was 
dull  on  percussion,  and  the  dulness  was  continuous  with  that  of  the  liver. 
The  child  was  of  a  sallow  appearance,  and  much  emaciated.  The  tumor 
had  been  detected  three  months  previously,  and  had  grown  rapidly. 
Haematuria  had  been  noticed  shortly  before  the  discovery  of  the  tumor. 

Autopsy. — The  tumor  was  found  to  involve  the  right  kidney;  it 
weighed  10  lbs.  142-  ozs. ;  it  was  smooth  on  the  surface,  and  to  the  touch 
felt  firm  in  some  places,  and  soft,  almost  fluctuating,  in  others.  Near  it 
lay  a  supplementary  tumor  about  the  size  of  an  orange.  On  cutting 
open  the  tumor  it  was  found  to  consist  of  soft  brain-like  substance,  con- 
taining two  or  three  large  cysts  filled  with  about  half  a  pint  of  dark 
fluid.  The  tumor  sprang  from  the  upper  portions  of  the  kidney,  and 
had  absorbed  all  the  organ  except  two  of  the  pyramids,  which  remained 
intact.  The  ureter,  the  left  kidney,  and  all  the  other  organs  were 
healthy.  The  liver  was  adherent  to  the  tumor,  and  the  ascending  colon 
ran  along  its  lower  border,  and  could  not  be  detected  in  front  of  the 
growth  during  life. 

Case  6.  Enormous  malignant  disease  of  the  left  kidney  ("Lancet," 
1856,  i.  626). — J.  B.,  aged  six  years,  was  admitted  into  the  Middlesex 
Hospital,  under  Dr.  Hawkins,  May  29,  1855.  J.  B.,  born  of  healthy 
parents,  was  one  of  a  family  of  ten  children,  of  which  five  were  still 
living,  the  others  having  died  of  acute  infantile  diseases.  When  the 
child  was  six  weeks  old  his  mother  noticed  that  both  left  extremities 
were  larger  than  the  right;  the  skin  was  looser,  and  the  muscles  she 
describes  as  being  less  firm  than  those  of  the  opposite  side.  She  was  so 
struck  with  the  difference  that  she  consulted  a  medical  man  about  it. 


ILLUSTRATIVE    GASES.  531 

At  three  years  of  age  the  chihl  had  whooping-cough,  and  shortly  after 
measles,  but  he  never  had  scarhit  fever.  The  abdonion,  the  niotlier 
believes,  was  always  rather  larger  than  could  be  considered  natural,  but 
this  had  not  been  to  a  marked  extent.  With  these  exceptions,  the  child 
had  fair  health  until  the  middle  of  April,  1855  (six  weeks  before  admis- 
sion), when  he  was  suddenly  seized  with  sickness;  and  from  his  appear- 
ance the  mother  believed  him  to  be  very  ill,  and  though  far  better  on 
the  following  day,  so  much  as  to  be  able  to  walk  out  of  the  house,  he 
did  not  regain  his  appetite  for  about  a  week.  During  this  illness  the 
mother  accidentally  discovered  a  tumor  in  the  upper  part  of  the  left  side 
of  the  abdomen.  It  then  appeared  to  be  almost  circular,  and  about  two 
inches  in  diameter.  It  was  not  perceptible  to  the  eye,  but  its  lower 
margin  could  be  distinctly  felt;  it  was  very  hard,  but  not  painful,  nor 
did  moderate  pressure  cause  any  inconvenience.  She  believes  that  it 
gradually  increased  in  size  after  she  first  discovered  it,  till  she  brought 
the  child  to  the  hospital,  and  during  this  time  she  noticed  that  he  had 
quite  regained  his  appetite,  which  had,  in  fact,  become  voracious,  and 
though  he  appeared  fatigued  after  moderate  exercise,  he  was  able  to 
walk  without  effort. 

State  on  Admission. — Rather  emaciated  ;  abdomen  very  much  swollen, 
especially  on  the  left  side,  where  the  veins  were  enlarged  and  tortuous ; 
the  left  extremities  were  considerably  larger  than  the  right,  owing  to  the 
soft  parts  being  much  firmer  and  the  muscles  apparently  better  devel- 
oped ;  there  was,  however,  no  difference  in  length.  Upon  manipulation, 
a  tumor  could  be  felt,  of  somewhat  globular  form,  about  three  inches  in 
diameter,  occupying  part  of  the  left  hypochondriac,  left  lumbar,  and 
umbilical  regions;  its  lower  margin  was  well  defined,  but  its  upper 
boundary  could  not  be  ascertained — the  dulness  on  percussion,  Avhich 
was  complete  over  all  parts  of  the  tumor,  being  there  continuous  with 
that  of  the  spleen.  The  patient  ate,  drank,  and  slept  well,  was  able  to 
sit  up  the  greater  part  of  the  day,  walked  frequently  up  and  down  stairs, 
and  did  not  complain  of  pain. 

From  this  time  the  patient  continued  under  observation  until  his  death, 
a  period  of  nearly  twelve  months.  The  tumor  continued  rapidly  to  grow, 
until  it  attained  enormous  proportions.  On  the  1st  of  August,  the  fol- 
lowing note  was  taken :  "  The  tumor  extends  half  an  inch  below  the 
umbilicus,  and  about  the  same  distance  to  the  right  of  the  mesian  line ; 
the  abdomen  generall}'  is  much  more  swollen,  and  the  veins  are  much 
larger.  The  patient  walks  about  the  garden  for  an  hour  or  two  every 
day,  and  though  taking  a  large  quantity  of  food,  and  eating  very  fre- 
quently, is  daily  becoming  more  emaciated.  He  appears  to  suffer  no 
inconvenience,  except  that  caused  by  the  bulk  of  the  tumor,  the  large 
size  of  the  abdomen  being  such  as  to  impede  progression.  He. com- 
plains of  thirst,  and  evinces  a  desire  to  drink  frequently  of  cold  water. 
The  bowels  act  with  regularity;  and  the  urine,  which  is  frequently 
voided,  and  in  quantity  rather  above  the  natural  standard,  presents  no 
abnormal  appearances." 

The  patient  continued  to  go  about  till  September,  and  to  walk  up 
and  down  one  flight  of  stairs  to  and  from  the  ward  without  assistance. 
About  the  middle  of  the  month,  after  having  spent  some  time  in  the 
garden  of  the  hospital,  he  fancied  himself  unable  to  get  back,  and  was 


632 


CANCER    OF    THE    KIDNEY. 


then  for  the  first  time  carried  upstairs.  After  this,  he  was  almost  con- 
stantly confined  to  his  bed.  The  tumor  gradually  increased  in  size  unt^^il 
his  death ;  for  some  time  previous  to  which,  indistinct  fluctuation  could 
be  felt  in  some  parts  of  it.  The  abdomen,  about  the  middle  of  Decem- 
ber, measured  in  circumference  36  inches,  and  at  the  end  of  March 
upwards  of  42  inches.  For  the  last  two  months  he  suffered  much  from 
dyspnoea ;  and  for  the  last  three  weeks,  had  constant  orthopnoea,  and 
daily  increasing  oedema  of  the  left  leg.  The  appetite,  however,  re- 
mained inordinate  till  the  last;  and  the  bowels,  which  had  continued  to 
act  regularly  till  within  a  short  time  of  his  death,  had  recently  become 
somewhat  constipated.     He  sank  gradually,  and  died  April  7,  1856. 

The  annexed  drawing  of  the  patient  was  taken  shortly  before  death, 
by  Mr.  J.  Z.  Laurence,  and  kindly  placed  by  him  at  my  disposal. 

Fig.  67. 


Enormous  cancer  of  the  left  kidn. 


From  a  drawing  by  J.  Z.  Laurence. 


Autopsy  (fifty-four  hours  after  death). — The  whole  of  the  abdomen, 
except  the  right  inguinal  region,  was  occupied  by  a  large  globular  tumor, 
anteriorly  firmly  adherent  to  the  parietes,  and  covered  by  peritoneum ; 
posteriorly,  lying  in  contact  with  the  psoas  muscle ;  the  small  intestines 
were  thrust  down  to  the  right  inguinal  region  ;  the  spleen  and  liver  were 


DIAGNOSIS.  533 

driven  upwardd  into  tlic  thorax  ;  the  wliolc  of  tlie  transverso  colon  was 
firmly  adherent  to  the  tumor;  and  a  ])ortion  of  the  descending  colon, 
which  ran  along  the  front,  was  for  a  short  distance  embedded  in  it.  The 
tumor,  when  removed  from  the  body,  weighed  thirty-one  ])ounds.  Traces 
of  kidney  structure  could  be  recognized,  as  if  spread  out  over  the  entire 
substance;  large  masses  of  medullary  cancer  were  visible  on  its  surface. 
Upon  section,  the  centre  was  f.uind  to  be  occupied  by  several  pints  of 
dark,  thick  fluid,  floating  in  which  were  several  fragments  of  the  broken- 
down  cancerous  mass  ;  the  more  solid  portions  varied  in  consistence  from 
that  of  firm  medullary  cancer  to  gelatinous  matter  in  a  semi-fluid  state, 
large  masses  of  it  being  found  in  every  stage  of  degeneration ;  the  kidney 
on  the  opposite  side  was  much  enlarged.  No  cancerous  deposit  was  found 
in  any  of  the  other  viscera.^ 

Diagnosis. — We  have  seen  that  in  nearly  all  cases  of  primary 
cancer  of  the  kidney,  a  palpable  tumor  exists  in  the  flank.  If 
profuse  hfematuria  coexist  with  such  a  tumor,  scarcely  a  doubt 
can  remain  as  to  the  seat  and  nature  of  the  disease.^  But  when 
there  is  no  hsematuria,  the  diagnosis  becomes  more  diificult ; 
hideed,  there  is  scarcely  any  morbid  condition  which  has  been 
so  frequently  misapprehended.  Renal  cancer  has  been  generally 
mistaken  for  enlargements  of  the  surrounding  organs — of  the 
liver,  spleen,  ovary,  or  uterus;  but  sometimes  for  ascites,  aneu- 
rism of  the  aorta,  or  perinephritic  abscess.  It  has  ako  been 
mistaken  for  tumors  of  the  kidney  of  a  different  character — for 
pyonephrosis,  hydatid,  cystic  degeneration,  and  hydronephrosis. 
Some  of  these  errors  were  doubtless  unavoidable;  but  most  of 
them  arose  from  an  imperfect  knowledge  of  the  diagnostic 
marks  of  renal  tumors,  and  from  the  undue  weight  attached  to 
the  absence  of  heematuria.  As  a  positive  sign,  associated  with 
abdominal  tumor,  hsematuria — profuse,  spontaneous,  and  recur- 
rent— is  of  the  highest  significance ;  but  its  absence  signifies 
comparatively  little.  In  nearly  half  the  cases  collected  by  me, 
haematuria  was  wholly  absent  from  the  first  to  last ;  and  in  those 
cases  in  which  hematuria  was  noted,  intervals  of  many  weeks 
or  months  elapsed  in  several  of  them,  during  which  the  urine 
was  perfectl}^  normal. 

In  those  numerous  cases,  therefore,  in  which  the  observer 
derives  no  help  from  the  examination  of  the  urine,  he  must  rely 
on  his  skill  to  ascertain  the  anatomical  relations  and  nature  of 
the  abdominal  tumor.  In  prosecuting  this  inquiry,  he  will. espe- 
cially endeavor  to  eliminate  tumors  of  the  liver,  spleen,  and 

1  Some  further  particulars  of  the  post-mortem  appearances  in  this  case  are  sup- 
plied b_y  Dr.  Van  der  Byl  (Path.  Soc.  Trans.,  vol.  viii.). 

2  The  coexistence  of  these  two  symptoms  is  not,  however,  absolutely  diagnostic 
of  renal  cancer.  In  a  case  of  enormous  enlargement  of  the  spleen  (leucocythsmic) 
in  the  Manchester  Infirmary,  there  was  profuse  ha?maturia  for  several  days.  After 
death,  some  months  subsequently,  the  kidneys  and  bladder  were  found  perfectly 
healthy. 


534  CANCER    OF    THE    KIDNEY. 

ovaries — these  being,  from  their  comparative  frequency,  the 
most  likely  to  lead  astray. 

If  the  intumescence  occupy  the  right  side,  it  may  be  distin- 
guished fr5m  hepatic  tumor,  especially  when  not  very  large,  by 
the  possibility  of  tracing  its  upper  limits  below  the  margins  of 
the  ribs;  the  side  of  the  hand  can  generally  be  so  inserted  at 
the  edge  of  the  ribs,  that  the  tumor  can  be  clearly  felt  to  lie 
below  it,  and  the  liver  above  it.  Along  this  line  a  coil  of  intes- 
tine usually  lies,  and  yields  a  tympanitic  sound  on  percussion. 
This  sign  is  lost,  however,  when  the  renal  growth  contracts  ad- 
hesions to  the  under  surface  of  the  liver;  also  when  it  projects 
disproportionately  into  the  right  hypochondrium,  and  displaces 
the  right  lobe  of  the  liver.  When  this  is  the  case,  assistance 
may  be  obtained  by  feeling  for  the  thin  margin  of  the  liver  as  it 
lies  applied  to  the  abdominal  wall.  Another  important  sign  in 
such  a  case  is  the  position  of  the  colon.  Hepatic  tumors  have 
no  intestine  in  front  of  them  (unless  there  be  malposition  of  the 
viscera),  and  yield  a  dull  note  over  their  entire  surface.  Renal 
tumors,  on  the  other  hand,  have  the  ascending  colon  in  front, 
passing  obliquely  from  below  upwards  and  to  the  left;  and  the 
passage  of  flatus  along  the  gut,  or  the  clear  percussion  note  over 
it,  will  rarely  fail  to  indicate  its  position. 

A  splenic  enlargement  is  distinguished  by  the  following  signs  : 
absence  of  the  descending  colon  in  front;  its  rigid,  somewliat 
thin  borders  (not  rounded);  its  extension  upwards  under  the 
ribs ;  its  mobility ;  generally,  a  tympanitic  note  is  obtained  in 
the  extreme  left  lumbar  region;  often,  on  deep  percussion,  a 
bowel  sound  is  perceived  through  its  substance,  which  is  not 
thick  (a  renal  tumor  is  absolutely  dull  on  the  deepest  percussion); 
antecedent  history  of  ague  or  remittent  fever,  or  evidence  of 
leucocythsemia  on  examination  of  the  blood ;  the  direction  of  the 
enlargement  is  downwards  and  inwards  to  the  epigastrium  and 
umbilicus,  and  not  toward  the  iliac  fossa.  It  also  rises  higher 
toward  the  axilla  than  a  renal  growth.  When  the  latter  rises 
from  the  upper  and  forepart  of  the  kidney,  and  pushes  forwards 
and  upwards  rather  than  downwards,  the  diagnosis  becomes 
very  difficult,  and  depends  mainly  on  the  absence  or  presence  of 
the  colon  in  front  of  the  enlargement,  and  hints  derived  from  the 
previous  history  or  the  state  of  blood  on  microscopic  examina- 
tion. 

When  the  tumor  presses  forwards  and  downwards  toward 
the  umbilicus  and  the  pubic  and  iliac  regions,  it  is  apt  to  be  mis- 
taken for  ovarian  tumor.  The  commemorative  symptoms  may 
here  yield  valuable  information,  though  the  statements  of  patients 
on  such  points  are '  alwaj^s  to  be  accepted  with  reserve.  An 
ovarian  growth  begins  in  the  iliac  fossa,  and  ascends ;  a  renal 
growth  begins  in  the  flank  between  the  ribs  and  the  crest  of  the 


PROGNOSIS.  535 

ilium,  and  descends.  An  ovarian  tumor  has  no  bowel  in  front 
of  it,  and  the  bowels  are  pushed  into  the  ]um])ar  ret^ion,  where 
a  clear  sound  can  be  elicited — exactly  in  the  spot  where  the 
dulness  is  most  complete  when  the  tumor  arises  from  the  kid- 
ney.^ This  last  sign  also  serves  to  distinguish  uterine  from 
renal  enlargements. 

An  encephaloid  kidney  can  only  be  confounded  with  ascites 
when  it  is  extremely  soft,  and  tills  the  entire  abdomen.  The 
two  conditions  may  be  distinguished  by  the  circumstance,  that 
in  ascites  both  flanks  are  dull,  whereas  in  renal  tumor  one  is 
dull  and  the  other  resonant. 

When  the  tumor  has  been  satisfactorily  made  out  to  be  con- 
nected with  the  kidney,  there  still  remain  difficulties  in  deciding 
its  nature.  Malignant  growths  generally  give  a  distinct  impres- 
sion of  their  solid  structure.  This  distinguishes  them  from 
hydatid,  purulent,  and  hydronephrotic  cysts;  but  the  consistence 
of  the  tumor  is  often  very  difficult  to  appreciate  :  if  it  be  small 
and  deep-seated,  and  the  abdominal  walls  thick,  the  sense  of 
fluctuation  in  a  fluid  cyst  may  be  exceedingly  obscure;  on  the 
other  hand,  encephaloid  tumors  sometimes  yield  a  quasi-fluctua- 
tion  which  is  very  deceptive.  In  these  doubtful  cases,  the  pres- 
ence of  pus,  or  blood,  or  hydatids  in  the  urine,  of  rigors,  of 
nephritic  colic,  or  of  cancerous  cachexia,  supplies  hints  which 
incline  the  judgment  in  this  or  in  that  direction. 

Prognosis. — The  ultimate  termination  is,  of  course,  always 
fatal.  In  judging  of  the  probable  survivorship  of  the  subjects 
of  renal  cancer,  the  age  of  the  patient  is  of  great  importance  : 
the  mean  duration  of  the  disease  is  at  least  three  times  as  great 
in  adults  as  in  children.  There  is,  however,  nothing  like  exact 
proportion  observed  in  this  respect.  In  a  girl  of  twenty-one, 
whose  case  is  described  by  Langstaff,  the  disease  lasted  (with 
hsematuria)  for  six  years.  Contrary  to  what  might  have  been 
expected,  the  occurrence  of  htematuria  does  not  appear  to  hasten 
the  final  catastrophe:  the  mean  duration  is  almost  exactly  the 
same  in  the  hemorrhagic  cases,  as  in  those  in  which  the  urine 
was  throughout  normal. 

The  disease  appears  in  some  cases  to  become  dormant  for  a 
while,  making  no  appreciable  progress  for  many  mouths.  In 
an  instance  of  this  kind  recorded  by  Dr.  Brinton,  the  stationary 
condition  (which  Dr.  B.  had  flattered  himself  might  pass  into 
permanent  obsolescence)  came  suddenly  to  an  end,  with  death 

1  A  case  is  reported  by  Dr.  Greenhalgh  ("  Tumors  Complicating  Pregnancy," 
St.  Earth.  Hosp.  Eeps.,  vol.  i.  85),  in  which  a  tumor  supposed  to  be  ovarian  acted 
as  a  complication  in  two  pregnancies  ;  and  the  propriety  of  removal  was  about  to 
be  entertained  when  the  patient  again  became  pregnant  She  died  without  obvious 
cause  three  weeks  after  delivery  at  the  full  term,  and  the  autopsy  showed  that 
the  supposed  ovarian  tumor  was  really  the  left  kidney  in  a  very  advanced  stage  of 
cerebriform  disease.     It  weighed  27  lb.  3  oz. 


636  CANCER  OF  THE  KIDNEY. 

of  the  patient,  through  copious  hemorrhage  into  the  tumor. 
("  Brit.  Med.  Journ.,"  June  13,  1857.) 

Treatment. — The  management  of  a  disease  so  hopeless  is  a 
melancholy  dntj.  When  the  tumor  is  painless,  and  the  urine 
natural,  there  is  little  for  the  practitioner  to  do  beyond  placing 
the  patient  in  favorable  hygienic  circumstances.  When  the 
tumor  is  tender,  or  there  are  signs  of  local  inflammation  in  its 
vicinity,  warm  baths  or  emoUent  applications  may  be  used  from 
time  to  time.  It  may  be  doubted  whether  it  is  prudent  to  inter- 
fere with  a  moderate  hsematuria.  The  losses  of  blood  do  not  on 
the  whole  act  disadvantageously.  When,  however,  the  hemor- 
rhage becomes  excessive,  means  must  be  used  to  control  it.  Ice 
may  be  applied  to  the  tumor,  and  acetate  of  lead  or  gallic  acid 
administered  internall3^  The  clots  which  form  in  the  ureter  and 
bladder  sometimes  occasion  the  most  poignant  suffering  by 
blocking  up  the  urethra,  and  causing  retention  of  urine.  The 
impacted  masses  should  be  pushed  back  into  the  bladder  by 
means  of  the  catheter,  and  the  coagula  broken  up  by  washing 
out  the  organ  with  warm  water. 

As  the  disease  advances,  severe  constitutional  irritation  sets 
in,  which  requires  to  be  palliated  by  opiate  and  other  anodyne 
medicines.^ 

B.— SECONDAEY  CANCER  OF  THE  KIDNEY. 

Secondary  cancerous  deposits  occur  in  the  kidneys,  in  the 
form  of  nodules  varying  from  the  size  of  a  pea  to  that  of  a 
marble  or  walnut.  Ten  to  twenty  such  nodules  are  not  unfre- 
quently  found  scattered  through  the  cortical  substance:  the 
intervening  renal  tissue  shows  no  sign  of  disease;  the  urine 
is  normal,  and  no  pain  or  other  symptom  betrays  their  presence 
during  life,  The  following  case  oflers  an  example,  marked  by 
some  very  unusual  incidents,  of  extensive  cancerous  disease  of 
the  urinary  organs,  involving  primarily  the  bladder  and  its 
vicinity,  extending  thence  to  both  kidneys,  of  which  the  right 
was  undergoing  sacculation  from  compression  of  the  corre- 
sponding ureter  by  the  cancerous  mass  at  the  base  of  the 
bladder. 

In  January,  1862,  I  was  requested  by  Dr.  Crompton  to  see  with  him 
a  shopkeeper,  aged  38,  who  was  then  suffering  from  hsematuria  and 
paralysis  of  the  bladder.     The  patient  gave  the  following  account  of 

1  A  curious  case  is  reported  in  the  Philadelphia  Medical  and  Surgical  Reporter 
for  1861,  p.  126.  A  man  of  57  had  had  a  tumor  in  the  right  hypochondrium  for 
six  years.  It  was  supposed  to  be  "  cystic  disease  "  of  the  liver  ;  and  his  surgeons 
deliberately  proceeded  to  remove  it  by  operation.  The  tumor  (which  weighed  2J 
lbs.)  v/as  accordingly  removed,  but  on  examination  it  proved  to  be  the  right  kid- 
ney, wholly  converted  into  an  encephaloid  mass.  The  patient  survived  fifteen 
days. 


SECONDARY    CANCER    OF    THE    KIDNEY.  587 

himself:  Three  years  previously,  without  known  cause,  "he  had  an 
attack  of  hieraaturia,  accompanied  with  excessively  frequent  micturi- 
tion, pains  in  the  back  and  bottom  of  the  belly,  but  without  vomiting 
or  retraction  of  the  testicle.  These  symptoms  passed  off,  under  medical 
treatment,  in  two  months,  and  (apparently)  comi)lete  recovery  soon 
ensued. 

After  an  interval  of  three  years,  during  which  the  patient's  health 
continued  in  every  respect  undisturbed,  the  present  attack  abruptly 
commenced.  The  patient  was  seized,  six  weeks  before  my  visit,  with 
violent  pains  in  the  loins  and  hypogastrium,  accompanied  by  painful 
and  excessively  frequent  micturition  and  bloody  urine.  All  these  symp- 
toms came  on  simultaneously.  There  was  neither  sickness  nor  vomiting. 
The  attempts  to  void  urine  were  incessant — every  ten  or  fifteen  minutes 
during  the  day,  and  so  constant  at  night  that  the  patient  scarcely 
obtained  any  sleep.  Matters  continued  thus  for  three  weeks ;  the 
patient,  meanwhile,  did  not  keep  his  bed,  and  he  attended,  as  well  as  he 
was  able,  to  his  duties  in  the  shop. 

But  a  new  train  of  symptoms  now  showed  themselves.  The  incessant 
micturition  was  succeeded  by  a  total  inability  to  empty  the  bladder,  and 
the  legs  and  belly  began  to  swell  rapidly.  At  this  conjecture  Dr. 
Crompton's  aid  was  obtained.  On  examining  the  patient  he  found  con- 
siderable ascites,  anasarca  of  the  lower  extremities,  and  retention  of 
urine.  Three  pints  of  a  sanguinolent  urine  were  immediately  with- 
drawn by  catheter  from  the  distended  bladder ;  the  patient  was  directed 
to  keep  his  bed,  and  treated  with  alkaline  diluents  and  nightly  seda- 
tives. Great  relief  followed  this  treatment,  but  the  patient  still  con- 
tinued unable  to  void  a  drop  of  urine  spontaneously,  and  catheterism 
had  to  be  practised  twice  a  day. 

His  condition  at  the  date  of  my  visit  was  as  follows :  There  was 
extreme  pallor  of  the  surface ;  considerable  emaciation ;  no  pyrexia  ; 
the  tongue  was  moist,  slightly  furred.  The  legs  were  no  longer  oede- 
matous,  but  considerable  ascites  still  remained.  The  bladder  was  dis- 
tended almost  to  the  umbilicus ;  there  was  no  pain,  and  the  loins  were 
not  sensitive  to  pressure;  nor  was  there  any  tumor  to  be  felt  in  the  renal 
region ;  the  movements  of  the  patient  were  active,  and  he  was  cheerful 
and  lively. 

About  a  quart  of  bloody  urine  was  removed  by  catheter,  A  little 
pure  blood  came  through  the  instrument  first,  then  almost  clear  urine, 
and  as  the  bladder  became  empty,  the  urine  again  became  ruddy,  the 
last  few  drops  being  almost  pure  blood.  Dr.  Crompton  stated  that  a 
little  bleeding  always  followed  the  morning  and  evening  catheterism, 

A  careful  examination  of  the  urine  yielded  the  following:  It  was 
feebly  alkaline  from  fixed  alkali  (derived  from  medicine") ;  specific 
gravity  1007  ;  on  standing,  the  blood-corpuscles  subsided,  and  formed  a 
very  red,  slightly  clotted  layer,  at  the  bottom  of  the  urine-glass.  Under 
the  microscope  there  were  found,  in  addition  to  the  blood-disks,  a  few 
corpuscles  with  cleft  nuclei — probably  pale  blood-corpuscles — but  no 
renal  elements — neither  epithelium,  nor  casts,  nor  any  suspicious  (quasi- 
cancerous)  cells  of  any  sort,  though  diligently  looked  for.  The  propor- 
tion of  albumen  was  no  more  than  corresponded  to  the  blood  present. 

The  patient  from  this  time  gradually  but  steadily  improved.     The 


538  CANCER    OP    THE    KIDNEY. 

bladder  slowly  recovered  the  power  to  expel  its  contents ;  the  urine 
became  less  and  less  bloody,  and  finally  clear,  and  free  from  albumen. 

Eight  months  afterwards  (August  26, 1862)  the  patient  waited  on  me. 
He  was  still-  pale  and  thin,  but  reported  himself  well,  and  had  for  the 
last  six  months  been  able  to  pursue  his  avocation. 

I  heard  nothing  more  of  the  case  until  June  22,  1863,  when  I  was 
summoned  to  visit  the  same  man  with  Dr.  Nesfield,  under  whose  care 
the  patient  came  after  Dr.  Crompton's  departure  from  town.  I  found 
him  in  a  desperate  condition — emaciated  to  a  skeleton  ;  so  weak  that  he 
could  not  turn  in  bed,  nor  raise  his  head  from  the  pillow.  There  was  no 
anasarca  nor  ascites.  Great  pain  was  complained  of  in  the  right  renal 
region,  but  no  tumor  or  fulness  existed  there.  The  urine  was  loaded 
with  pus,  and  highly  ammoniacal.     Six  days  after,  the  patient  died. 

Autopsy. — On  opening  the  abdomen  and  pushing  aside  the  small  intes- 
tines, a  cancerous  mass,  half  as  large  as  the  fist,  was  found  implicating 
the  base  of  the  bladder,  especially  about  the  entrance  of  the  right  ureter. 
Within  the  viscus,  a  soft  sprouting  fungus  of  the  size  of  a  hen's  egg,  was 
seen  springing  from  the  trigone  ;  it  was  rounded  in  shape,  elevated  about 
an  inch  above  the  level  of  the  mucous  membrane,  and  very  red.  On 
and  about  it,  occupying  the  inequalities  of  its  surface,  lay  a  quantity  of 
calcareous  or  phosphatic  matter,  deposited  in  irregular  masses.  Small 
masses  of  a  similar  nature  had  been  observed  to  come  away  with  the 
urine  for  some  weeks  before  death. 

The  right  kidney  was  a  little  larger  than  natural ;  it  felt  flaccid  and 
hollowed.  On  section,  six  cancerous  nodules  as  large  as  marbles,  and 
several  smaller  ones,  were  counted  in  the  cortical  substance.  None  of 
these  were  softened,  nor  communicated  in  any  way  with  the  pelvis  of  the 
kidney.  The  organ  was  sacculated  to  a  considerable  extent.  The 
pyramids  were  in  great  part  absorbed,  and  the  remainder  of  the  renal 
structure  was  converted  into  a  reddish,  leathery  substance.  The  pelvis 
and  infundibula  were  much  dilated.  The  ureter  was  enlarged  to  the 
size  of  the  index  finger,  and  near  its  entrance  into  the  bladder,  its  calibre 
was  almost  effaced  by  the  cancerous  mass  at  the  base  of  the  bladder, 
through  which  it  passed.  Broken  fragments  of  calcareous  matter  lay 
scattered  in  the  dilated  pelvis,  which,  together  with  the  ureter,  contained 
a  quantity  of  urinous  ammoniacal  pus. 

The  left  kidney  contained  eight  or  ten  nodules  similar  to  those  in  the 
right.  The  intervening  renal  tissue  was  perfectly  healthy;  the  ureter 
was  free,  and  the  pelvis  undilated. 

This  case  presented  several  points  of  difficulty.  At  the  time 
of  my  first  visit  the  symptoms  indicated  pretty  clearly  an 
affection  of  the  bladder:  and  as  no  stone  could  be  detected  on 
sounding,  and  no  pus  passed  with  the  urine,  the  probability  of 
the  existence  of  a  bleeding  fungus  seemed  strong.  The  other 
possibility  was  renal  calculus.  The  previous  history  favored 
the  latter  view  ;  the  patient  had  recovered  perfectly  from  his 
first  attack  of  hsematuria  three  years  before — a  result  quite 
conformable  with  the  idea  of  renal  calculus,  but  much  less  so 
with  that  of  fungus  of  the  bladder.     Then  again,  how  explain 


APPENDIX.  5^9 

the  ascites  and  anasarca?  Thoy  could  not  be  attributed  to  the 
losses  of  blood  and  hydricniia  conserjuent  thereu[)on,  for  they 
passed  away  before  the  htematuria  ceased.  It  a[)peared  more 
likely,  that  the  dropsical  symptoms  and  the  paresis  of  the 
bladder  were  companion  phenomena,  of  a  paralytic  nature,  pro- 
duced by  the  reilex  results  of  the  antecedent  intense  irritability 
of  the  bladder,  acting  upon  the  nerves  of  the  bladder  and  of  the 
bloodvessels  of  the  lower  half  of  the  body. 


APPENDIX. 

Sakcoma  of  the  Kidney. — [See  Robson,  "Brit.  Med.  Journ.," 
1876,  I.  p.  232;  Baginski,  "Deutsch.  Med.  Wochenschr.,"  1876, 
]^o.  10;  Geddings,  "Trans.  Americ.  G-ynfec.  Society,"  1877,  p. 
479;  Whitehead  and  Dreschfeld,  "Brit.  Med.  Journ.,"  1881,  II. 
p.  741;  Fotherby,  "Brit.  Med.  Journ.,"  1882,  I.  p.  157;  Heath, 
"Brit.  Med.  Journ.,"  1882,  II.  p.  100;  Abercrombie,  "Pcith. 
Trans.,"  xxxi.  p.  168;  Bay  and  Thornton,  "Path.  Trans.,"  xxxii. 
p.  142;  also  see  Yirch.  and  Hirsch.,  "  Jahresber,,"  1880,  vol.  ii. 
p.  212;  and  Cornil  and  Ranvier,  "Histologic  Pathologique," 
2d  edition,  1884,  vol.  ii.  p.  638.) 

Many  of  the  cases  mentioned  above  under  the  head  of  Cancer 
of  the  Kidney  were  observed  before  the  differentiation  between 
carcinoma  and  sarcoma  had  been  generally  demonstrated.  It  is 
probable  that  a  considerable  number  of  the  older  cases  would 
now  be  classed  with  the  latter  variety  of  tumor.  In  those  cases 
in  which  the  sarcomatous  nature  of  the  growth  has  been  recog- 
nized, the  tumor  has  usually  been  found  to  be  composed  of 
small  round  cells,  or  of  these  mixed  with  spindle  cells.  Lympho- 
sarcoma of  the  kidney  is  by  no  means  rare,  especially  in  young 
subjects. 

Clinically  no  sign  has  yet  been  observed,  which  will  serve  to 
distinguish  sarcoma  from  carcinoma  of  the  kidney.  The 
clinical  features  of  such  growths  may  be  illustrated  by  the  fol- 
lowing account  of  a  case  under  the  care  of  my  colleagues,  Dr. 
Dreschfeld  and  Mr.  Walter  Whitehead. 

A.  L.,  aged  46,  came  to  the  out-patients'  department  of  the  Man- 
chester Royal  Infirmary  for  the  first  time  on  April  4, 1882,  complaining 
of  the  occasional  passage  of  blood  in  his  urine.  He  stated  that  he  had 
always  enjoyed  good  health;  he  had  suffered  from  gonorrhoea,  but  not 
from  syphilis.  He  was  a  well-built  but  spare  man  of  very  dark  com- 
plexion ;  he  had  a  slightly  atheromatous  pulse  and  beginning  arcus 
senilis.  On  the  right  side  of  the  abdomen  a  small  firm,  freely  movable 
globular  tumor  could  be  felt ;  its  upper  border  was  about  one  inch  below 
and  separate  from  the  liver;  its  lower  border  was  in  a  line  with  and 
about  two  inches  to  the  right  of  the  umbilicus.     Percussion  gave  a  dull 


540.  CANCER    OF    THE    KIDNEY. 

sound,  and  no  bowel  could  be  detected  over  the  tumor.  It  was  perfectly 
painless.  The  patient  had  been  aware  of  its  presence  for  some  time,  but 
felt  no. inconvenience  from  it.  Percussion  of  the  lumbar  regions  behind 
gave  a  duller  sound  on  the  right  than  on  the  left  side,  but  no  fulness 
could  be  detected  on  that  side.  The  urine  was  uniformly  dark  red, 
containing  a  considerable  amount  of  blood  intimately  mixed  with  it. 
Microscopically  examined,  it  showed,  besides  blood-corpuscles,  some 
large  round  cells  with  large  nuclei,  which  filled  up  nearly  the  whole  of 
the  cell.  There  were  no  renal  casts.  The  remaining  organs  were  nor- 
mal. A  diagnosis  was  made  of  tumor  of  the  right  kidney,  probably  of 
sarcomatous  nature. 

In  the  further  progress  of  the  case  the  tumor  increased  in  size.  It 
still  remained  painless,  and  extended  downwards  and  to  the  side,  so  that 
it  could  be  easily  grasped  by  one  hand  being  applied  to  the  right  lumbar 
region  behind  and  the  other  over  the  tumor  in  front ;  it  could  thus 
be  moved  both  laterally  and  vertically;  the  surface  of  the  tumor  felt 
smooth  and  inelastic. 

At  the  beginning  of  August  the  patient  complained  of  feeling  weaker, 
and  of  suffering  from  flatulence  and  occasional  vomiting.  The  case 
being  one  where  an  operation  was  indicated,  Mr.  Whitehead  removed 
the  growth  on  September  5th,  but  the  patient  died  on  September  9th. 
The  growth  proved  to  be  a  large  round-celled  sarcoma  of  the  kidney, 
and  at  the  autopsy  no  secondary  growths  were  found. 

A  sarcoma  in  which  striated  muscular  fibres  are  found,  occurs 
very  rarely  and  always  in  young  children.  Specimens  of  such 
a  tumor  were  exhibited  at  a  meeting  of  the  Pathological  Society 
on  'Nov.  1,  1881,  by  Mr.  Eve  and  Dr.  Dawson  Williams.  The 
explanation  offered  by  Cohnheim  of  the  presence  of  muscular 
fibres  in  these  tumors,  is  that,  owing  to  a  faulty  segmentation  of 
the  protovertebrse,  some  of  the  germinal  muscle-cells  are  mixed 
from  the  first  with  the  rudiments  of  the  uro-genital  organs  and 
these  germinal  cells  afterv^ards  develop  into  a  pathological  new 
growth.  The  Committee  of  the  Pathological  Society  considered 
that  the  tumors  mentioned  above  were  developed  from  the 
remains  of  the  Wolffian  body.  Only  twelve  such  cases  have 
been  as  yet  described,  and  of  these  the  following  is  a  list : 

Eberth— Virch.  Arch.,  vol.  55,  p.  518. 

Cohnheim — Ibid.,  vol,  65,  p.  64. 

Brodowski— Ibid.,  vol.  67,  p.  205. 

Marchand— Ibid.,  vol.  73,  p.  289. 

Brosin— Ibid.,  vol.  96,  p.  453. 

Kocher  and  Langhans — Deutsche.  Zeitsch.  f.  Chirurg.,  Bd.  ix. 

Huber — Deutsches  Arch.  f.  klin.  Medicin.,  vol.  xxiii.  p.  312. 

Landsberger — Berl.  klin.  Wochensch.,  1877,  p.  497. 

Osier  (2  cases) — Journal  of  Anat.  and  Physiol.,  vol.  14,  p.  229. 

Eve — Path  Trans.,  vol.  xxxi.  p.  164. 

Williams — Ibid. 


CHAPTEK   XJ. 

BENIGN  GROWTHS  IN  THE  KIDNEY. 

In  the  records  of  medicine  a  number  of  cases  n)ay  be  foiuic], 
in  which  the  kidneys  were  the  seat  of  adventitious  growths  of 
osseous,  fibrous,  fibro-fatty,  cartilaginous,  or  glanduhir  tissue. 
Generally  speaking,  such  growths  do  not,  unless  they  are  large 
enough  to  constitute  a  palpable  tumor  in  the  abdomen,  produce 
any  appreciable  symptoms  during  life;  and  they  offer  more  of  a 
pathological  than  clinical  interest.    They  are  all  extremely  rare. 

1.  Osseous  Growths, — Mention  has  already  been  made  of  the 
ossification  which  sometimes  takes  place  in  the  fibrous  septa 
which  separate  the  compartments  of  a  sacculated  kidney  (see 
p.  456). 

Sometimes  a  fibrous  or  cartilaginous  tumor  growls  in  the  sub- 
stance of  the  kidney,  and  subsequently  ossifies,  transforming 
a  large  part  of  the  organ  into  a  bony  mass.  The  tunica  propria 
has  also  been  known  to  undergo  ossification.  Rayer  states  that 
Dr.  EUiotson  sent  to  him  two  bony  shells  formed  by  the  ossified 
tunica  propria  and  pelvis  of  the  kidney,  taken  from  a  man  who 
died  with  symptoms  of  apoplexy. 

2.  Fibrous  and  Fibro-fatty  Growths. — Dickinson  and  Bris- 
towe  have  each  recorded  a  case,  in  which  the  major  part  of  the 
kidney  was  replaced  by  a  morbid  growth,  composed  of  a  matrix 
of  fibrous  tissue,  in  the  interstices  of  which  were  soft  masses  of 
free  fatty  matter  unenclosed  in  cells.  In  Dickinson's  case  the 
tumor  weighed  6  lb.  7J  oz.,  and  formed  a  perceptible  tumor  in 
the  right  hypochondrium.  After  death,  a  coil  of  intestine  was 
found  in  front  of  the  tumor,  but  so  compressed  and  empty  that 
its  nature  was  not  likely  to  be  recognized  during  life.  Wilks 
records  a  case  in  which  a  tumor  was  found  on  the  right  side  of 
the  abdomen  six  years  before  death ;  it  was  partly  solid  and 
partly  fluid,  and  was  by  some  diagnosed  as  cancerous.  On  post- 
mortem examination,  the  right  kidney  was  found  converted  into 
a  tumor  the  size  of  a  young  child's  head.  This  was  found  to 
consist  of  a  solid  growth  on  one  side  bearing  a  striking  resem- 
blance to  the  fibro-cartilaginous  tumors  sometimes  met  with  in 
the  neck,  but  which  was  found,  on  microscopic  examination,  to 
consist  exclusively  of  fibrous  tissue;  and  on  the  other  side  a 
cyst  was  found,  which  on  section  was  seen  to  be  due  to  the  enor- 
mously distended  pelvis.  The  new  growth  had  slowly  invaded  and 


542  BEISIGN    GROWTHS    IN    THE    KIDNEY. 

destroyed  the  renal  tissue,  while  it  gradually  distended  the  cap- 
sule, and  thus  preserved  the  general  form  ojp  the  kidney. 

In  the  case  described  by  Godard,  the  lower  half  of  the  kidney 
was  converted  into  a  large  mass  of  ordinary  adipose  tissue.  A 
calculus  of  considerable  size  was  lodged  in  the  dilated  pelvis. 
A  somewhat  similar  transformation  is  described  by  Dr.  Hullett 
Browne,  complicated  with  calculous  pyelitis,  and  renal  fistula 
opening  in  the  left  loin  ("  Path.  Soc.  Trans.,"  xiii.  132). 

Adipose  tissue  is,  in  other  cases,  deposited  in  great  quantity, 
not  in,  but  around  the  kidneys,  so  as  evidently  to  interfere  with 
their  functions.  In  the  museum  of  the  Manchester  School  of 
Medicine  there  is  a  preparation  in  which  a  pale  and  atrophied 
kidney  is  enveloped  in  a  firm  investment  of  dense,  granular, 
fibro-fatty  tissue,  fully  an  inch  thick.  The  same  tissue  pene- 
trates deeply  into  the  hilus,  so  as  to  compress  the  bloodvessels 
and  excretory  channels. 

3.  Lymphatic  Growths. — Yirchow,  Friedreich,  and  Bottcher 
have  described  growths  or  deposits  in  the  kidneys  of  leucocy- 
thsemic  individuals,  similar  to  those  found  under  the  same  cir- 
cumstances in  the  spleen  and  lymphatic  glands. 

4.  Syphilitic  Deposits  in  the  Kidneys. — It  seems  well  ascer- 
tained that  the  waxy  or  lardaceous  type  of  chronic  Bright's  dis- 
ease is  frequently  due  to  constitutional  syphilis.  Out  of  145 
cases,  collected  by  Fehr,  34  were  attributed  to  this  cause  [see  p. 
406);  and  in  27  cases  of  constitutional  syphilis  examined  by 
Dr.  Moxon,^  the  kidneys  were  found  lardaceous  in  no  less  than 
12  instances. 

The  occurrence  of  gummy  tumors  and  cicatrices  (such  as 
occur  in  the  liver)  is  rare,  though  not  unknown,  in  the  kidneys 
of  syphilitic  persons.  Both  Cornil  and  Lancereaux  give  ex- 
amples. In  Lancereaux's  case  there  were  found  on  the  surface 
and  in  the  thickness  itself  of  the  cortical  substance  of  the 
kidneys  small  tumors  of  the  size  of  a  pea,  of  a  yellowish-white 
color,  and  presenting,  on  examination  by  the  microscope,  the 
cellular  and  nucleated  elements  found  in  gummy  syphilitic 
tumors  elsewhere.^ 

Dr  Moxon  gives  a  remarkable  case,  in  which  a  gummy  tumor, 
as  large  as  a  small  potato,  existed  in  the  left  kidney  of  a  syphi- 
litic woman.  It  had  a  regular  nodose  outline,  and  was  composed 
of  a   yellowish    substance,   quite  uniform   in   appearance,   and 

1  A  Contribution  to  the  History  of  Visceral  Syphilis,  by  Dr.  Moxon.  Guy's  Hosp. 
Eep.,  1868. 

2  Lancereaux.  Treatise  on  Syphilis — Syd.  Soc.  Trans.,  vol.  i.  p.  298.  A  case 
of  syphilitic  gummy  tumors  of  the  kidney  is  recorded  at  great  length  (with  a 
drawing)  by  Paolucci  from  the  Clinique  of  Prof.  Cantani,  of  Naples,  in  II  Morgagni 
for  June,  1874,  p.  413.  )S'ee  also  Professor  Greenfield,  Kesume  of  Eenal  Pathology 
in  the  Syden.  Society's  Atlas. 


BENIGN     GROWTHS    IN    THK     KIDNEY.  543 

which  was  firm,  hurd,  and  toui^li.  It  yielded  no  juice  on  Hcrap- 
ing.  Under  the  microscope,  the  mass  was  found  to  consist  of 
small  corpuscles  crowded  together,  first  obscuring,  and  then  de- 
stroying and  replacing  the  proper  tissue,  and  then  themselves 
perisliing  into  a  heap  of  fat  grains  and  globules — all  wljich 
exactly  corresponds  to  the  usual  character  of  syphilitic  gummata. 
The  general  character  of  tlie  kidney  was  that  of  the  large  [)ale 
lardaceous  kidney/ 

5.  Wagner  has  published  two  cases  in  which  one  kidney  was 
converted  into  a  large  tumor,  composed  apparently  of  a  con- 
bination  of  epithelial  structure,  fibrous  tissue,  and  glandular 
(pancreatic)  sarcoma.  Both  were  female  children — one  nine 
months  and  the  other  eight  years  old. 

1  The  power  of  the  syphilitic  poison  to  produce  acute  Bright's  disease  appears 
doubtful.  Lancereaux  cites  two  cases  of  albuminuria  reported  by  Perroud,  which 
accompanied  the  secondary  period  of  syphilis — some  four  or  six  months  after  the 
indurated  chancre — and  which  appear  to  have  issued  favorabl3\  The  late  Mr. 
Bradley,  of  this  town  (Brit.  Med.  Journ.,  1871,  i.  p.  116),  has  al.so  recorded  a  case 
of  acute  Bright's  disease,  with  general  anasarca  in  an  infant  sufi'ering  from  con- 
genital syphilis.  The  renal  affection  subsided  pari  pasHU  with  the  disappearance 
of  the  cutaneous  syphilis.  Until  further  proof,  it  may  be  doubted  whether  these 
were  not  examples  of  a  fortuitous  coincidence  of  two  independent  morbid  condi- 
tions. 


CHAPTER  XII. 

TUBERCLE  OF  THE  KIDNEY. 

Deposits  of  tubercle  in  the  kidney  may  be  frimary  or  secon- 
dary. In  the  former  case  the  kidney  and  its  appendages  are  the 
seat  of  extensive  disease,  which  runs  on,  attended  with  severe 
urinary  symptoms,  generally,  if  not  always,  to  a  fatal  conclu- 
sion. In  the  latter,  the  deposits  form  as  a  part-manifestation  of 
general  tuberculosis,  or  constitute  incidents  in  the  course  of 
primary  tubercle  of  the  lungs,  intestines,  or  some  other  organ ; 
secondary  deposits  rarely  give  rise  to  symptoms,  and  are  mostly 
unsuspected  until  the  autopsy. 

The  comparative  frequency  of  tubercle  in  the  kidney  may  be 
judged  of  by  the  following  numbers,  which  must  be  understood 
to  embrace  both  primary  and  secondary  deposits — the  latter 
being,  especially  in  children,  by  far  the  most  frequent.  Out  of 
1317  tuberculous  subjects,  examined  in  the  Pathological  Institu- 
tion of  Prague  (out  of  a  total  of  6000  bodies),  tubercle  in  the 
kidneys  was  found  74  times,  or  in  the  proportion  of  5.6  per 
cent,  of  all  tuberculous  subjects.^  Among  315  tuberculous 
children,  Rilliet  and  Barthez  found  tubercle  in  the  kidneys  49 
times,  or  in  the  proportion  of  15.7  per  cent.  Prom  these  statis- 
tics we  may  gather  that  the  kidney  is  nearl}^  three  times  more 
liable  to  deposits  in  tuberculous  children  than  in  tuberculous 
adults.^ 

A— PKIMAKY  TUBERCLE   OF   THE   KIDNEYS. 

( Tuberculous  Pyeiitis. ) 

The  statements  made  in  the  following  pages  are  mainlj^  based 
on  an  analysis  of  35  cases,  derived  from  various  sources. 

Morbid  Anatomy. — The  disease  (which  always  implicates 
more  or  less  extensively  the  excretory  apparatus  as  well  as  the 
gland  itself)  begins  in  the  kidney,  and  extends  downwards  into 
the  pelvis,  ureter,  and  bladder;  or  it  begins  in  the  pelvis,  and 
spreads  upwards  into  the  kidney,  and  downwards  towards  the 
bladder;  or  all  these  parts  may  be  invaded  simultaneously  or 

1  Prager  Vierteljarsch  ,  Bd.  1.  S.  1  (1856). 

2  I  omit  the  statistics  of  Dr.  Chambers,  because  there  are  some  discrepancies  in. 
his  tables  which  1  have  been  unable  to  reconcile. 


MORBID    A  N  A  'I'  O  M  Y  546 

in  quick  succession.  In  the  kidney,  the  deposit  begins  in  tiie 
form  of  gray  or  yellow  nodules  in  the  cortical  part:  these  after- 
wards coalesce  into  larger  masses  of  crude  tubercle,  and  extend 
into  the  pyramids.  These  masses  at  length  soften  in  the  centre, 
and  eventually  open  into  the  infundibula.  In  this  way  abscess- 
like cavities  arise,  with  anfractuous  boundaries  of  tuberculous 
matter,  which  communicate  with  the  pelvis,  and  discharge  pus 
and  broken  masses  of  tubercle  into  the  stream  of  urine. 

In  the  pelvis  and  ureter,  the  deposit  first  begins  in  the  sub- 
mucous cellular  tissue,^  where  it  forms  a  rough,  granular,  semi- 
transparent  or  opaque  layer.  It  consequently  softens  and 
disintegrates,  causing  extensive  destruction  of  the  superjacent 
mucous  membrane,  which  is  discharged  in  shreds  with  "the 
urine,  mixed  with  pus  and  blood.  The  deposit  is  sometimes  so 
abundant  and  uniform  in  the  ureter,  that  that  tube  is  converted 
into  a  thick  rigid  cylinder,  of  which  the  available  bore  is  greatly 
narrowed,  or  even  altogether  obliterated.  In  a  specimen  sub- 
mitted to  me  by  Dr.  Leech  (case  to  be  presently  related),  the 
interior  of  the  pelvis  was  thickly  encrusted  with  calcareous 
matter,  and  one  of  the  ureters  was  completely  occluded  near  its 
centre  by  an  oval  mass  of  tubercle  about  the  size  of  a  horse-bean. 

Extensive  destruction  of  the  renal  tissue  eventually  takes 
place,  both  from  the  encroachment  of  the  tubercle  masses,  and 
from  sacculation  and  dilation  of  the  organ  by  the  blocking  up  of 
the  ureter  (pyonephrosis).  Sometimes  no  vestige  of  the  secreting 
tissue  remains ;  but  more  commonly  certain  portions  are  pre- 
served, and  these  may  present  a  moderately  healthy  appearance, 
or  be  far  advanced  in  degeneration.  In  other  cases  the  ureters 
are  open  and  dilated,  and  admit  free  passage  to  the  urine,  pus, 
and  tubercular  debris ;  the  kidney  then  maintains  its  normal 
dimensions,  or  it  may  even  be  contracted. 

Actual  tumor  (pyonephrosis),  detectable  during  life,  is  men- 
tioned in  7  out  of  our  35  cases.  It  seldom  reached  great  dimen- 
sions, but  in  one  instance  related  by  Ammon,  it  filled  the  entire 
side  of  the  abdomen,  from  the  false  ribs  to  the  crest  of  the  ilium. 

The  disease  is  sometimes  limited  to  one  side,  but  much  more 
frequently  it  invades  both.  Out  of  32  cases  which  supply  in- 
formation on  this  point,  the  two  sides  were  afiected  in  19,  and 
one  side  alone  in  13  cases.  Of  the  latter,  the  right  kidney  was 
aiFected  7  times  and  the  left  6  times. 

In  addition  to  the  kidney  itself,  and  its  immediate  appen- 
dages (pelvis  and  infundibula),  the  disease  almost  invariably 
involved  the  ureter  (in  30  out  of  32  cases),  and  very  frequently 
the  bladder  (in  21  cases).     The  urethra  was  involved  in  7  cases. 

1  See  an  observation  by  Dr.  Handfield  Jones,  in  the^^first  vol.  of  the  Path.  Soc. 
Trans.,  p.  283. 

35 


546  TUBERCLE    OF    THE    KIDNEY. 

In  the  male  sex,  the  disease  not  unfrequently  implicates  the 
generative  organs  (prostate  nine  times,  vesiculpe  seminales  six 
times,  testicles  four  times) ;  but  it  is  otherwise  in  the  female 
sex.  Out  of  nine  females,  in  only  one  instance  (to  be  presently 
related)  were  any  of  the  generative  organs  involved/ 

The  disease  very  rarely  runs  its  entire  course  without  the 
occurrence  of  tuberculous  deposits  in  other  and  unconnected 
parts  of  the  body.  Thirty  cases  were  examined  with  sufficient 
minuteness  to  supply  information  on  this  point.  The  lungs 
were  affected  28  times;  the  abdominal  glands,  14  times;  the 
intestines,  19  times;  the  osseous  system,  5  times;  the  perito- 
neum, 5  times;  the  spleen,  3  times;  and  the  liver,  once. 

In  one  case  the  ulceration  (tuberculous)  in  the  bladder  opened 
a  communication  with  the  rectum  (Basham) ;  in  another  a 
vesico-vaginal  fistula  resulted  from  a  similar  cause  (Mosler) ; 
in  a  third,  the  suppurated  kidney  burst  into  the  peritoneal  sac 
(Lundberg,  Schmidt's  "  Jahrb.,"  Bd.  xci.  S.  74). 

Etiology. — The  direct  exciting  cause  of  renal  tubercle  is 
generally  inscrutable.  Cold  is  the  cause  most  frequently  men- 
tioned ;  the  patients  came,  in  several  instances,  from  conspicu- 
ously tuberculous  families.  Men  are  more  liable  to  this  com- 
plaint than  women — in  the  proportion  of  21  of  the  former  to  12 
of  the  latter.  JSTo  age  is  altogether  exempt.  The  youngest  case 
noted  was  a  child  of  three  years  and  a  half,  and  the  oldest 
(mentioned  by  Dittrich,  and  not  included  in  the  table)  was  a 
man  of  seventj'-one;  but  the  greater  number  occurred  in  the 
middle  periods  of  life.  The  following  table  gives  the  precise 
ages  in  31  cases  : 

From    0  to  10  years 4  cases. 

"      10  to  20     " 5     " 

"      20  to  30     " 6     " 

"      30  to  40     " 9     " 

"      40  to  50     " 6     " 

"      50  to  60     " 2     " 

Symptoms. — The  symptoms  are  mainly  those  of  chronic 
pyelitis,  conjoined,  in  a  considerable  majority  of  the  cases, 
with  those  of  chronic  cystitis.  The  complaint  begins  with  a 
dull  pain  in  one  or  both  lumbar  regions,  accompanied  with 
frequent  micturition.  At  the  same  time  the  urine  becomes 
turbid,  and  sometimes  mixed  with  blood.     When  the  disease 

1  The  mutual  independence  of  tuberculosis  of  the  urinary  and  generative 
systems  in  the  female,  is  further  shown  in  a  converse  manner  by  Dittrich.  Out  of 
45  cases  of  tuberculosis  of  the  female  genital  organs,  he  only  found  one  in  which 
the  disease  also  implicated  the  urinary  organs  (Arcbiv  der  Heilkunde,  1868,  p. 
804).  Virchow  describes  an  additional  example  of  this  rare  conjunction,  in  which 
urinary  tuberculosis  was  associated  with  secondary  deposits  in  the  vagina  (Archiv 
fiir  Path.  Anat.,  Bd.  v.  S.  405). 


S  Y  M  J' T  O  M  S  .  547 

is  fully  established,  the  urine  is  charged  with  a  large  quantity 
of  pus,  which  forms  a  thick,  yellowish  layer  at  the  bottom  of 
the  vessel.^  Blood  is  also  usually  present,  either  in  microscopic 
quantity,  or  sufliciently  to  tinge  the  urine.  The  lucniaturia  is, 
however,  never  profuse ;  in  several  instances  it  was  noted  that 
small,  thready  clots  of  blood  were  passed.  Under  the  micro- 
scope, there  are  found,  in  addition  to  the  pus  and  blood-corpus- 
cles, a  number  of  oval  and  irregularly  tailed  cells  from  the 
bladder  and  upper  urinary  passages,  together  with  granular 
detritus,  broken  masses  of  softened  tubercle,  shreds  of  connec- 
tive tissue  and  elastic  fibres. 

The  reaction  of  the  urine  is  feebly  acid.  Very  few  exceptions 
to  this  rule  exist,  and  those  are  due  to  ammoniacal  decomposi- 
tion of  the  urine  from  detention  in  some  part  of  its  course,  as 
in  Hosier's  case,  from  the  tumid  state  of  the  external  genitals. 
The  urine  is  necessarily  albuminous  from  the  presence  of  pus, 
but  usually  only  in  a  slight  degree.  Casts  of  tubes  are  only 
mentioned  once.  Micturition  is  always  excessively  frequent; 
often  dolorous.  In  two  cases,  temporary  alleviation  of  the 
pains  followed  each  micturition  :  this  was  not  observed  in  other 
cases. 

As  the  disease  advances,  great  emaciation  takes  place,  accom- 
pianied  with  hectic  fever,  sometimes  marked  by  chills  and  rigors 
of  tolerably  regular  recurrence.  Persistent  pains  are  felt  in  the 
back,  in  the  lower  part  of  the  abdomen,  and  often  along  the 
urethra. 

When  the  kidney  is  sacculated  and  enlarged,  so  as  to  form  a 
tumor  in  the  flank,  the  swelling  is  usually  painful ;  it  may,  or 
may  not,  yield  distinct  fluctuation.  Sometimes  the  tumor  dis- 
plays variations  in  its  size:  it  enlarges  when  the  ureter  is 
dammed-up  by  the  discharged  debris,  and  becomes  more  painful, 
at  the  same  time  the  quantity  of  pus  in  the  urine  diminishes — 
or,  if  the  stoppage  be  complete,  temporarily  disappears.  Anon 
the  course  of  the  pus  and  urine  is  reestablished,  and  the  tumor 
subsides  and  becomes  less  painful. 

In  the  progress  of  the  case,  or  towards  its  termination,  the 
lungs  and  intestines  generally  betray  the  advance  of  tuberculous 
disease.  Cough  and  oppression  of  the  chest,  or  uncontrollable 
diarrhoea,  make  their  appearance.  Gastric  symptoms  (nausea, 
vomiting,  hiccough)  are  unusual ;  but  in  some  cases,  as  in  the 
two  about  to  be  related,  they  are  a  marked  feature  of  the  com- 
plaint. The  absence  of  intestinal  tuberculosis,  accompanied 
with  obstinate  constipation,  appears  to  favor  their  occurrence. 

If  both   kidneys  are  affected,  the   extensive   destruction   of 

1  At  intervals  the  urine  may  be  copious  and  limpid,  containing  no  albumen, 
and  giving  no  deposit.     (Tapret.) 


548 


TUBEKCLE    OF    THE    KIDNEY. 


secreting  tissue  is  liable  to  give  rise  to  ursemic  phenomena.  The 
quantity  of  the  urine  is  usually  below  the  average ;  but  excep- 
tionally, as  in  a  case  recorded  by  Sir  Risdon  Bennett  ("  Path. 
Soc,  Trans.,"  viii.  p.  284),  the  urine  is  abundant  and  of  low 
specific  gravity.  Usually  death  occurs  from  the  exhaustive 
effects  of  the  protracted  and  profuse  suppuration,  or  from  the 
severity  of  the  pulmonary  or  intestinal  complications. 

The  following  cases  will  serve  as  illustrations  of  the  course 
of  the  disorder  and  of  the  appearances  generally  found  after 
death. 

Case  1.  Tuberculous  disease  of  the  right  kidney  and  ureter,  and  of  the 
bladder,  urethra,  and  prostate;  absentee  of  left  kidney  and  ureter. — J.  P.,  a 
packing-case  maker,  set.  23,  was  admitted  into  the  Manchester  Royal 
Infirmary,  under  my  care,  March  27, 1871.  He  was  suffering  from  old- 
standing  discharge  of  large  quantities  of  pus  with  the  urine,  mixed  with 
a  little  blood.     The  disease  had  existed  nine  months  ;  the  emaciation 

Fig.  68. 


Tlie  right  kiduej'  of  J.  P.  laid  open — about  one-half  of  the  actual  size. 

was  extreme.  There  were  distinct  signs  of  consolidation  in  the  apices 
of  both  lungs,  but  no  cough  or  expectoration.  Profuse  night-sweats  and 
an  elevated  temperature  in  the  evenings  bore  evidence  of  hectic  fever. 
The  tongue  was  dry  and  red;  the  lower  part  of  the  belly  was  the  seat 


ILLUSTRATIVE    CASES.  540 

of  a  dull  aching,  and  micturition  was  both  frequent  and  painful.     He 
sank  from  exhaustion  a  few  days  after  his  admission  into  hospital. 

Autopsy  (30  hours  after  death). — Pleura  universally  adherent  on  right 
side ;  no  adhesions  on  left  side.  There  was  a  large  amount  of  gray 
tubercle  iii  the  upper  lobes  of  both  luv.rjs,  the  lower  lobes  being  free; 
the  tubercle  was  associated  with  a  quantity  of  pigmentary  deposit.  No 
cavities  or  purulent  exudation  observed.  Heart  and  pericardium  healthy. 
Liver  enlarged,  soft,  and  friable,  preseuting  a  pale  surface  on  section  ; 
spleen  healthy.  The  left  kidney, suprarenal  capsule,  and  ureter  were  absent. 
The  right  kidney  was  considerably  enlarged,  and  weighed  14i  ounces. 
On  section,  there  was  a  large  cavity  at  the  upper  part,  occupying  one- 
fifth  of  the  entire  kidney,  filled  with  pus,  and  two  other  very  much 
smaller  purulent  cavities  in  the  central  part  of  the  organ  (see  Fig.  08). 
The  cortical  portion  was  seen  to  be  much  hypertrophied,  but  pale,  except 
the  parts  situated  between  the  pyramids,  which  were  dotted  over  with 
red  points ;  the  pyramidal  portion  was  atrophied  and  almost  entirely 
absent.  The  pelvis  was  dilated  and  divided  into  pouch-like  enlarge- 
ments, the  lining  membrane  being  studded  over  with  small  whitish 
deposits  of  tubercular  matter,  which  could  be  traced  along  the  ureter  to 
the  bladder,  and  thence  along  the  urethra.  About  half  an  ounce  of  pus 
escaped  from  the  ureter  on  section.  The  ureter  was  dilated  at  its  com- 
mencement and  near  its  termination,  where  it  easily  admitted  the  fore- 
finger ;  but  the  opening  into  the  bladder  was  so  small  that  it  could  not 
be  detected  until  a  probe  had  been  passed  from  without.  A  slight 
depression  marked  the  position  for  the  entrance  of  the  left  ureter,  of 
which,  however,  no  trace  could  be  found.  The  fundus  of  the  bladder 
was  covered  with  tubercular  deposit,  which  was  limited  to  this  part,  the 
body  and  summit  being  entirely  free.  The  mucous  membrane  of  the 
affected  part  was  much  broken  down  in  structure,  and  in  parts  almost 
ulcerated  through  ;  the  walls  of  the  bladder  and  ureter  were  consider- 
ably thickened.  The  spermatic  cords  and  vesiculce  seminales  were  normal, 
being  perfectly  free  from  tubercle.  The  prostate  was  involved  in  the 
disease,  and  partially  disintegrated. 

Case  2.  Pericarditis,  tvlth  subsequent  adhesion;  cirrhosis  of  liver,  and 
enlarged  spleen,  follotved  eight  years  after  by  tube^^cular  pyelitis  and  gen- 
eral tuberculosis. — I  first  saw  G.  P.,  a  grocer,  set.  27,  in  1860.  He  was 
then  suffering  from  plastic  pericarditis,  with  immense  enlargement  of 
the  spleen  and  considerable  enlargement  of  the  liver.  His  illness  had 
been  brought  about  by  intemperance.  He  was  in  the  habit  of  taking 
great  quantities — as  much  as  a  quart  a  day — of  gin.  From  this  illness 
he  slowly  recovered,  at  least  so  far  as  to  be  able  to  go  about  and  look 
after  his  business;  but  the  enlargement  of  the  spleen  remained.  I'saw 
this  man  occasionally  until  1867.  He  persisted,  with  some  intermis- 
sions, in  his  intemperate  habits,  and  failed  in  his  business.  In  August, 
1867,  he  appeared  among  my  out-patients  at  the  Infirmary.  The  spleen 
was  now  decidedly  smaller,  and  the  heart  appeared  quite  healthy ;  but 
he  was  complaining  of  frequent  micturition  and  of  passing  blood  with 
the  urine.  The  blood  first  appeared  in  the  previous  June,  and  had  con- 
tinued ever  since.  In  jSTovember,  1867, 1  admitted  him  as  an  in-patient 
into  the  Infirmary.     His  condition  was  then  as  follows  :    he  was  some- 


560  TUBERCLE    OF    THE    KIDNEY. 

what  emaciated,  skin  moist,  finger-ends  slightly  clubbed,  no  oedema 
anywhere,  pulse  96,  respiration  20,  tongue  dry  and  fiery-red.  The  abdo- 
men was  rather  tumid  ;  the  liver  extended  from  the  nipple  to  two  inches 
below  the  costal  margin ;  the  spleen  measured  nine  inches  vertically. 
The  urine  was  loaded  with  pus,  and  with  enough  blood  to  give  it  a  full 
red  tinge.  The  proportion  of  blood  to  pus  in  this  case  was  much  greater 
than  is  usually  the  case  in  tubercular  pyelitis.  There  were  no  casts  in 
the  urine,  and  the  albumen  did  not  exceed  the  proportion  due  to  the 
admixture  of  pus  and  blood.  The  patient  remained  in  the  Infirmary 
fourteen  days,  and  underwent  little  or  no  change.  He  did  not  keep 
his  bed.  Pulse  varied  from  70  to  80,  respiration  20.  He  continued  to 
pass  rather  more  pus  and  rather  less  blood  ;  but  there  was  always  enough 
of  the  latter  to  color  the  urine,  and  often  small  clots.  The  tongue  re- 
tained the  same  "  broiled  ham  "  appearance.  It  is  to  be  remarked  that 
the  spleen  was  now  much  smaller  and  the  liver  larger  than  when  I  first 
saw  him  seven  years  before. 

He  was  again  made  an  out-patient,  and  I  saw  him  from  time  to  time. 
He  continued  without  much  change,  passing  purulent  and  bloody  urine 
at  very  frequent  intervals,  until  the  end  of  January,  1868,  when  he  was 
seized  with  uncontrollable  vomiting,  under  which  he  sank  on  Feb- 
ruary 2d. 

Autopsy. — Emaciation  only  moderate ;  no  oedema.  The  liver  was 
cirrhotic  in  an  advanced  degree,  the  spleen  enlarged ;  but  both  organs 
(especially  the  spleen)  were  much  smaller  than  they  had  been  eight 
years  ago.  The  lungs  were  thickly  studded  with  gray  granulations 
from  base  to  apex.  The  pericardium  was  adherent  throughout,  but  it 
was  not  thickened,  and  the  heart  itself  was  healthy.  Both  kidneys 
were  deeply  aflfected  with  tuberculous  pyelitis.  The  pelves  were  much 
enlarged,  and  studded  with  broken-down,  ulcerated  tubercle.  A  few 
■  masses  of  yellow,  unsoftened  tubercle  were  found  in  the  right  kidney, 
about  the  bases  of  the  pyramids.  The  pyramidal  portions  were  in  great 
part  destroyed  by  the  encroachment  of  the  distended  pelves.  The  ureters 
were  lined  throughout  with  ulcerated  tubercle  ;  the  bladder  and  urethra 
also  were  partially  affected  in  a  similar  manner.  The  peritoneum  was 
adherent  almost  throughout,  and  contained  here  and  there  tuberculous 
granulations. 

The  next  case  occurred  in  the  practice  of  my  colleague,  Dr. 
Leech,  who  kindly  furnished  me  wnth  the  notes  of  the  case,  and 
with  the  anatomical  preparations. 

Case  3.  Tubercle  in  both  kidneys,  ureters,  bladder,  and  urethra;  in  the 
prostate  gland  and  vesiculce  seminales ;  also  in  the  lungs  and  mei^enterio 
glands. — W.  P.,  set.  53,  a  brewer,  had  been  ailing  three  years.  His  dis- 
ease began  with  pain  and  difficulty  in  micturition.  The  urine  was  thick, 
and  sometimes  mixed  with  blood ;  though  he  made  water  very  fre- 
quently, he  did  not  think  that  he  passed  an  excessive  quantity.  Except 
for  short  intervals,  he  had  suffered  from  the  same  symptoms  for  the  last 
three  years.  His  urine  had  been  occasionally  quite  clear,  but  generally 
thick,  and  often  dark.  He  had  never  complained  of  much  pain  in  the 
lumbar  region. 


ILLUSTRATIVE    CASES.  551 

About  nine  months  before  liis  deutli,  the  i)aticnt  begun  to  vomit  fre- 
quently, especially  after  taking  food  ;  for  the  last  five  months  vomiting 
after  meals  had  been  constant,  frequently  accompanied  with  pain  in  the 
epigastrium. 

The  general  health  had  gradually  failed  during  the  last  three  years; 
but  he  lost  flesh  and  strength  more  rapidly  during  the  last  twelve 
months.  lie  worked  occasionally,  however,  up  to  six  months  before  his 
death.  For  many  months  he  had  felt  a  gnawing  pain  just  over  the 
pubes,  increased  by  pressure;  this  was  less  severe  during  the  last  six 
months  of  life. 

Five  months  before  his  death  the  edges  of  the  meatus  urinarius  began 
to  ulcerate,  and  the  ulceration  gradually  widened  the  orifice  to  d(juble 
its  natural  size.  In  the  course  of  the  last  six  months  two  small  abscesses 
formed  in  the  scrotum,  both  of  which  were  opened,  and  subsequently 
healed. 

He  had  been  in  the  habit  of  taking  large  quantities  of  beer,  but  not 
much  spirits ;  he  contracted  gonorrhoea  many  years  ago,  but  he  never 
had  any  venereal  sores. 

About  a  week  before  his  death,  he  was  in  the  following  condition : 
Emaciation  very  great ;  countenance  sallow ;  meatus  urinarius  much 
enlarged  and  ulcerated  ;  severe'pain  is  felt  along  the  urethra  and  in  the 
glans  penis,  especially  after  voiding  urine.  The  ulceration  can  be  seen 
to  extend  for  a  depth  of  nearly  half  an  inch  into  the  urethra.  The 
urine  contains  abundance  of  pus  and  a  small  quantity  of  albumen  ;  no 
casts  Avere  found.  The  urine  is  passed  very  frequently,  and  in  small 
quantities.  He  vomits  after  everything  he  takes,  even  after  simple 
water,  or  a  little  brandy  and  water.  What  he  brings  up  is  a  brownish 
liquid;  it  contains  no  sarcinae ;  sometimes  a  little  blood  comes  up;  but 
he  thinks  it  is  derived  from  the  back  part  of  the  nose,  where  he  feels 
pain  and  rawness.  The  abdomen  is  flat,  or  rather  depressed ;  the  epi- 
gastrium is  very  painful  on  pressure.  In  the  right  hypochondrium  a 
little  hard  mass  can  be  felt  on  deep  palpation,  and  there  is  dulness  at 
this  spot  on  deep  percussion.  There  is  also  considerable  pain  on  pres- 
sure in  the  hypogastric  region.  He  complains  of  aching  pain  over  the 
lower  ribs  on  both  sides.  The  bowels  are  very  constipated,  and  have 
been  so  for  some  time. 

The  day  before  his  death  he  vomited  a  considerable  quantity  of  blood. 
The  sickness  and  vomiting  were  somewhat  relieved  for  a  short  time  by 
effervescing  draughts,  with  morphia,  but  only  for  a  day  or  two.  After- 
wards the  vomiting  became  continuous ;  he  vomited,  or  attempted  to 
vomit,  every  half  hour  or  so.  There  was  no  delirium  till  the  day  before 
his  death,  which  took  place  on  the  27th  of  December,  1864. 

Autopsy. — Stomach  of  normal  size ;  mucous  membrane  congested  in 
parts  ;  no  thickening  of,  or  deposit  in,  the  walls ;  pyloric  valve  thickened 
and  somewhat  contracted.  Liver  healthy.  Mesenteric  glands  much 
enlarged ;  some  of  them  contained  small  cretaceous  masses.  Lungs  : 
left  contracted  and  full  of  miliary  tubercles ;  right  contained  hard 
masses  of  tubercle  at  apex. 

Kidneys:  left  of  natural  size;  on  the  outside,  Avhite,  slightly  raised 
spots  are  seen  through  the  fibrous  covering.  On  removing  the  latter_, 
the  surface  of  the  cortex  is  seen   marked  wdth  small  white  nodules, 


552  TUBERCLE    OF    THE    KIDNEY. 

some  of  which  are  collected  into  patches;  to  these  patches  the  tunica 
propria  is  tightly  adherent.  On  section,  several  large  cavities  are 
opened  into,  containing  pus.  The  largest  of  these  is  situate  in  the 
upper  part  of  the  kidney,  and  is  lined  by  a  smooth  membrane,  except 
at  its  opening  into  the  pelvis,  where  some  calcareous  matter  is  deposited. 
All  the  other  cavities  open  into  the  pelvis  ;  some  of  them  have  irregular 
anfractuous  boundaries  of  softening  tubercle ;  these  likewise  are  more 
or  less  completely  lined  with  calcareous  matter,  composed  of  carbonate 
and  phosphate  of  lime.  The  whole  of  the  pelvis  is  encrusted  with  the 
same  earthy  material,  which  can  also  be  followed  for  some  distance 
down  the  ureter.  In  the  cortical  and  pyramidal  parts  of  the  kidney 
intervening  between  the  cavities,  the  renal  tissue  is  studded  with  soft 
nodules  of  disintegrating  tubercle,  varying  in  size  from  a  pin's  head  to 
a  pea.  The  submucous  tissue  of  the  pelvis  and  ureter  is  the  seat  of  a 
thick  granular  layer  of  gray  tuberculous  matter,  softened  in  parts ;  the 
ureter  is  thereby  converted  into  a  thick,  rigid,  uneven  tube,  with  a 
narrowed  calibre. 

The  right  kidney  is  much  smaller  than  the  left.  The  pyramids  are 
occupied  by  abscess-like  cavities  full  of  pus.  The  septa  between  the 
pyramids  are  in  some  places  preserved,  in  others  partially  broken  down. 
The  pelvis  is  greatly  contracted,  almost  obliterated ;  in  one  or  two  places 
there  are  narrow  communications  between  the  sacs  of  pus  in  the  pyra- 
mids and  the  unobliterated  parts  of  the  pelvis.  The  ureter  is  completely 
occluded,  midway  between  the  kidney  and  the  bladder,  by  an  oval 
nodule  of  yellow  crude  tubercle  about  the  size  of  a  horse-bean. 

The  whole  of  the  mucous  membrane  of  the  bladder  is  strewed  with 
deposits  of  tubercle.  These  are  sparsely  scattered  and  scanty,  except 
over  the  trigone ;  here  the  deposit  is  very  abundant,  in  the  form  of 
small  granulations  rather  larger  than  a  pin's  head.  A  few  similar 
granulations  are  seen  in  the  prostatic  part  of  the  urethra. 

The  prostate  gland  is  somewhat  enlarged  on  the  under  surface,  and 
contains  two  small  tuberculous  nodules.  One  of  the  vesiculce  semihales 
also  contained  soft  tuberculous  matter. 

Case  4.  Tubercle  of  the  left  kidney,  pelvis,  and  ureter ;  of  the  bladder 
and  urethra ;  also  of  the  pericardium,  lungs,  peritoneum,  and  mesenteric 
glands. — A  needlewoman,  33  years  of  age,  strongly  built,  whose  father 
seems  to  have  died  of  phthisis,  took  cold  in  consequence  of  a  severe 
wetting  in  the  autumn  of  1859,  about  a  year  before  her  death.  Her 
first  symptoms  were  those  of  cystitis,  with  moderate  fever.  The  fever 
soon  disappeared  ;  but  the  pain  in  the  bladder,  which  radiated  upward 
into  the  left  loin,  and  the  urgency  and  burning  pain  of  micturition, 
together  with  a  turbid  condition  of  the  urine,  remained,  and  persisted 
through  the  winter.  Impairment  of  digestion  and  emaciation  were  also 
observed. 

About  half  a  year  from  the  commencement  of  her  complaint,  fever- 
ishness  returned  ;  pain  and  urgency  of  micturition  increased,  and  blood 
appeared  in  the  urine.  From  this  time  (February,  1860)  the  patient 
became  the  object  of  exact  observation.  She  was  already  markedly 
emaciated,  pale  with  a  hectic  flush  on  each  cheek ;  she  suffered  from 
headache,  often  from  palpitation ;  the  appetite  was  bad,  the  bowels  con- 


1 L  hUti T  K  A  T  1  V  E    CASES.  558 

fined,  and  there  was  moderate  fever  ;  the  desire  to  pass  water  was  con- 
stant, and  the  pain  in  the  hhidder,  shooting  into  the  left  loin,  great. 
The  urine  was  scanty,  tinged  with  blood,  with  a  thick  deposit  of  pus  and 
blood-clots.  The  urethra  was  somewhat  swollen  and  tender;  and  after 
micturition  the  bladder  still  contained  several  ounces  of  unevacuated 
urine.  These  symptoms  maintained  themselves  without  essential  cliange 
for  six  months,  until  she  died  on  the  4th  of  September. 

The  loss  of  flesh  continued  without  interruption,  and  reached  an 
extreme  degree.  Hectic  fever  prevailed,  with  evening  exacerbations — 
the  temperature  rising  to  38.5°-39.5°  C,  and  sometimes  to  40''  C.  From 
the  end  of  March,  severe  paroxysms  of  chills  and  rigors,  followed  by 
heat  and  sweating,  occurred  at  irregular  intervals.  At  the  end  of  July, 
night  sweats  and  bed-sores  were  noted. 

Gastric  symptoms  were  throughout  prominent.  They  increased  and 
diminished.  For  days  together  the  patient  would  suffer  from  severe 
epigastric  pains,  nausea,  vomiting,  and  disgust  of  food.  From  the  end 
of  May,  she  occasionally  suffered  from  paroxysms  of  hiccough,  lasting 
several  hours.  In  the  last  moments  of  life  she  was  troubled  with  bilious 
vomiting,  and  towards  the  end  she  had  diarrhoea. 

The  quantity  of  urine  was  invariably  scanty,  though  the  patient  some- 
times drank  a  good  deal.  The  proportion  of  blood  in  the  urine  gradually 
diminished  from  the  beginning  of  March,  and  the  blood-clots  sometimes 
were  absent  for  several  days,  yet  the  blood  never  disappeared  altogether. 
The  quantity  of  pus  increased.  From  May  onward  there  appeared 
occasionally  in  the  urine  sloughy  shreds  of  cellular  tissue,  elastic  fibres, 
swollen  bladder-epithelium,  and  little  yellow  broken  masses  of  detritus. 
On  the  8th  of  July,  some  epithelial  renal  casts  were  for  the  first  time 
discovered  in  the  urine. 

At  the  end  of  April  a  vaginal  examination  revealed  the  existence  of 
a  small  hard  swelling  at  the  base  of  the  bladder  (this  was  proved  at  the 
autopsy  to  be  due  to  a  tuberculous  thickening  at  the  point  of  entrance 
of  the  left  ureter). 

The  patient  began  to  complain  of  pains  in  the  chest  soon  after  her 
admission  into  hospital ;  then  a  dry  cough  came  on,  and  later  on,  a 
slight  dulness  on  percussion  was  perceived  in  the  left  infra-clavicular 
region.  In  the  later  periods  she  also  complained  of  oppression  in  the 
chest;  but  she  never  expectorated,  and  there  never  existed  any  of  the 
more  open  symptoms  of  pulmonary  tuberculosis. 

It  was  a  singular  and  inexplicable  circumstance,  that  a  short  time 
before  death  an  improvement  took  place,  which  lasted  several  days;  all 
the  pains  and  the  fever  disappeared,  the  appetite  returned,  and  the 
strength  was  so  far  restored  that  she  was  able,  unassisted,  to  sit  up, 
although  before  she  was  scarcely  able  to  turn  in  bed. 

Autopsy. — Emaciation  had  reached  the  most  extreme  degree.  The 
brcdn  and  its  membranes  were  healthy.  Some  tuberculous  granulations 
were  found  in  the  otherwise  healthy  pericardium  at  the  base  of  the  right 
auricle.  Heart  healthy.  The  lungs  and  pleurce  were  studded  with  gray 
and  yellow  granulations.  The  left  apex  contained  several  gray  nodules 
as  large  as  w'alniits.  The  liver  contained  no  tubercle,  but  its  peritoneal 
investment  was  thickly  covered  with  gray  granulations;  the  organ  was 
adherent,  by  its  convex  surface,  to  the  abdominal  wall.     A  mass  of 


55i  TUBERCLE    OF    THE    KIDNEY, 

tuberculous  glands,  as  large  as  a  pigeon's  egg,  occupied  the  portal 
fissure. 

The'  perito7ieum  covering  the  spleen,  intestines,  and  mesentery  was 
thickly  covdred  with  tuberculous  granulations.  The  mucous  membrane 
of  the  intestinal  canal  was  throughout  free  from  tubercle. 

The  right  kidney  was  itself  healthy,  together  with  its  pelvis  and  ureter; 
but  its  capsule  was  studded  with  miliary  tubercles. 

The  left  kidney  presented  its  usual  form  and  size,  but  its  capsule  was 
converted  into  a  thick  membranous  covering  which  enclosed  the  degen- 
erated gland.  In  the  upper  half  of  the  organ  were  found  one  large 
and  two  smaller  cavities,  separated  incompletely  from  each  other  by 
undestroyed  renal  tissue.  These  cavities  were  tilled  with  a  greenish- 
yellow  mucopurulent  fluid,  and  their  anfractuous  walls  were  composed 
of  reddish  and  yellow  cheesy  deposit.  The  reddish  and  yellow  mate- 
rials, in  the  form  of  smaller  and  larger  nodules,  were  deposited  in  close 
contact  with  each  other.  These  cavities  stood  in  direct  continuation 
with  the  raucous  membrane  of  the  pelvis,  which  was  similarly  degen- 
erated and  thickened.  In  the  lower  half  of  the  organ  was  another  and 
a  larger  cavity,  similarly  constituted  with  the  others,  and,  like  them, 
communicating  with  the  pelvis. 

The  undestroyed  portions  of  the  kidney  had  a  pale  red  color,  and  con- 
tained in  the  lower  parts  of  the  gland  several  small,  roundish,  grayish, 
and  yellowish  cheesy  nodules.  The  coats  of  the  left  ureter  were  several 
lines  thick,  firm,  and  rigid  ;  the  mucous  membrane  tumid,  friable,  yel- 
lowish, and  the  seat  of  numberless  miliary  tubercles ;  in  many  places 
the  ureter  was  superficially  eroded  into  roundish  ulcers,  with  firm  raised 
edges. 

The  walls  of  the  bladder  were  three  lines  thick ;  its  cavity  was  con- 
tracted ;  its  inner  surface  reddened,  and  riddled  with  ulcers  having 
tuberculous  margins.  The  peritoneal  surface  of  the  viscus  was  studded 
with  tubercles.  The  serous  coverings  of  the  generative  organs  were  in 
the  same  condition,  but  the  organs  themselves,  with  the  exception  of  the 
ovaries,  were  healthy.  The  ovaries  contained  several  gray  tuberculous 
nodules. 

The  lumbar  glands  contained  cheesy  matter.  (Kussmaul,  "  Wiirzb. 
Med.  Zeitsch.,"  Bd.  iv.  S.  24.) 

The  Duration  of  the  disease  varies  from  a  few  months  to  two 
or  even  three  years.  Only  14  out  of  our  35  cases  supply 
moderately  exact  information  on  this  point.  Five  died  under 
six  months;  live  in  six  to  twelve  months;  three  in  one  to  two 
years ;  and  one  survived  three  years. 

The  Diagnosis  of  tubercle  in  the  kidney  and  its  appendages 
turns  mainl}'  on  the  existence  of  signs  of  chronic  pyelitis,  joined 
with  collateral  evidence  of  tuberculosis,  and  the  absence  of  any 
other  assignable  cause  of  pyelitis  (calculi,  hydatids,  etc.).  Ex- 
amination of  the  urine  furnishes  important  information;  not 
only  is  the  urine  abundantly  purulent,  but  it  also  contains 
a  quantity  of  granular  debris,  sometimes  mixed  with  broken 
masses  of  tuberculous  matter  (insoluble  in  acetic  acid),  shreds 
of  connective  tissue,  and  beautiful  meshes  of  elastic  fibres  from 


TREATMENT.  555 

the  cast-otf  patches  of  disintegrated  mucous  mcTiibrane.  JJuring 
recent  years  the  tubercle-bacillus  has  been  discovered  in  such 
urine  by  Rosenstein/  and  also  by  Babes.^  Its  detection  adds 
great  support  to  the  diagnosis.^  The  severity  of  the  general 
symptoms — the  progressive  and  great  emaciation  and  failure  of 
strength — must  also  be  taken  into  account.  When  evidence  of 
pulmonary  phthisis,  or  ulceration  of  the  bowels  exist,  they 
supply  a  valuable  indication;  but  it  should  not  be  forgotten 
that,  although  tubercles  almost  invariably  exist  in  these  cases 
in  tlie  lungs  or  intestines,  they  often  run  a  latent  course,  or  are 
not  in  a  sufficiently  advanced  stage  to  be  clinically  detected. 

From  cancerous  pyelitis  (without  tumor)  the  diagnosis  is 
generally  established  without  difficulty  by  the  characters  of  the 
urine.  In  cancer,  the  urine  (if  not  normal)  is  bloody  rather 
than  purulent;  in  tubercle,  it  is-  always  immensely  purulent, 
and  only  slightly,  or  not  at  all,  bloody. 

It  need  scarcely  be  stated  that  primary  tubercle  of  the  kidney 
is  not  capable  of  diagnosis  until  it  has  softened  and  commenced 
to  be  discharged. 

The  Prognosis  is  excessively  grave,  if  not  absolutely  fatal. 
A  hope  of  recovery  can  only  be  conceived  to  exist  in  those  cases 
(if  there  be,  indeed,  any  such)  in  which  the  deposits  are  confined 
to  one  kidney,  without  implicating  the  excretory  appendages. 
One  does  not  see,  a  priori,  why  tuberculous  masses  in  the  kidney 
should  not  be  evacuated  by  the  urinary  channels,  in  the  same 
way  that  similar  masses  in  the  lungs  are  sometimes  evacuated 
by  the  bronchial  tubes,  provided  the  tendency  to  the  deposition 
of  tubercle  be  arrested.  Kidneys  apparently  undergoing  a  pro- 
cess of  this  sort  have,  in  ver}^  rare  instances,  been  found  in  the 
inspection  of  the  bodies  of  persons  who  bear  the  marks  of  past 
tuberculosis.  Dr.  Bennett  describes  a  case  in  which  it  appeared 
probable  that  such  a  train  of  events  had  taken  place.* 

If  the  disease  involve  both  sides,  or  implicate  the  bladder  and 
urethra,  or  be  complicated  with  pulmonary  or  intestinal  tuber- 
culosis, no  hope  of  a  favorable  issue  can  be  entertained. 

The  Treatment  should  be  conducted  on  the  principles  which 
guide  the  management  of  tuberculous  diseases  generally.  The 
strength  should  be  supported  by  cod-liver  oil,  mineral  acids,  and 
other  tonics,  combined  with  a  nutritious  diet  and  a  moderate 
allowance  of  stimulants.      Opiates   are   generally    requi*red  to 

1  Ceiitralbl.  f  Med.  Wissench.,  1883,  p.  65.  ^  i})i(j.^  p.  145. 

^  To  detect  tubercle-bacilli,  allow  the  urine  to  stand  for  a  short  time,  and  jjlace 
a  little  of  the  pus  between  two  cover  glasses.  Dry  each  glass  carefully  ;  stain 
like  phthisical  sputum,  with  aniline-water-magneta,  decolorize  with  2o  per  cent, 
solution  of  nitric  acid,  and  s'tain  the  ground  substance  with  methyl-blue.  The 
tubercle-bacilli  then  appear  red,  while  the  other  matters  in  the  field  of  the  micro- 
scope are  blue. 

*  Clin.  Lects.,  2d  ed.,  p.  734. 


556  TUBERCLE    OF    THE    KIDNEY. 

insure  rest  and  some  alleviation  of  pain.  These  means  may  be 
supplemented  b}^  the  occasional  use  of  the  warm  bath.  To 
check  excessive  secretion  of  pus,  the  muriated  tincture  of  iron 
may  be  given  in  doses  of  15  to  20  drops  thrice  a  day  (see  Treat- 
ment of  Chronic  Pyelitis,  p.  470). 

B.— SECONDAEY   TUBERCLE   OF    THE    KIDNEY. 

Secondary  tubercle  is  deposited  in  the  kidneys  in  the  form  of 
minute  yellowish  nodules  and  granulations,  varying  in  size  from 
a  pin's  head  to  a  pea.  The  little  masses  are  scattered  over  the 
surface  and  through  the  interior  of  the  gland,  chiefly  in  the 
cortical  part.  In  places  they  run  together  into  groups  or  patches 
as  large  as  a  sixpence  or  a  shilling.  The  intermediate  parts  of 
the  kidney  are  either  altogether  healthy,  or  only  show  signs  of 
congestion  immediately  around  the  deposits.  When  the  pyramids 
are  affected,  the  little  granulations  sometimes  evince  a  disposition 
to  assume  a  linear  arrangement  parallel  with  the  straight  ducts. 
Such  deposits  are  not  uncommon  in  acute  general  tuberculosis ; 
much  less  frequent  in  persons  who  have  died  from  pulmonary  or 
intestinal  tubercle.  The  deposits  are  generally  confined  to  the 
substance  of  the  kidney,  without  participation  of  the  pelvis  and 
ureter. 

Secondary  tubercle  is  greatly  more  common  in  the  kidneys 
than  primary.  Out  of  91  cases  of  renal  tubercle  tabulated  by 
Dr.  Chambers,  76  were  secondary,  and  15  primary.  Both  kid- 
neys are  nearly  always  implicated  in  the  former. 

As  a  rule,  no  symptoms  referrible  to  the  kidneys  are  observed 
during  life.  The  urine  presents  merely  febrile  characters,  and 
contains  neither  pus  nor  blood.  If,  however,  the  deposit  take 
place  with  excessive  rapidity,  pains  in  the  back  and  other  indi- 
cations of  renal  disturbance  may  occur.  In  the  following  case, 
by  Colin,  deposition  of  tubercle  in  the  kidneys,  occurring  in 
the  course  of  chronic  phthisis,  was  thus  diagnosticated  during 
life. 

A  soldier,  aged  twenty,  suffering  under  chronic  phthisis,  was 
suddenly  seized  with  violent  lumbar  pains  accompanied  with 
an  intense  rigor.  Next  day,  these  pains  were  so  violent  as  to 
cause  the  patient  to  cry  out;  the  lumbar  muscles  were  in  a 
state  of  strong  contraction,  and  exquisitely  tender.  There  was 
high  fever,  with  a  corresponding  state  of  the  urine.  Three  days 
later,  acute  meningitis  set  in,  which  destroyed  the  patient  in  four 
days.  The  autopsy  revealed  exudation  of  lymph  (but  no  tubercle) 
on  the  meninges ;  old  pulmonary  mischief,  with  recent  deposit 
of  miliary  granulations  in  the  lungs;  tbe  spleen  was  studded 
with  similar  granulations.  The  kidneys  were  markedly  enlarged, 
the  capsule  easily  detached ;    about  thirty  yellow  nodules,  as 


SECONDARY    TUBERCLE    OP^    THE    KIDNEY.  .557 

large  as  pins'  heads,  were  scattered  on  their  surface.  On  the 
convex  border  of  each  kidney  there  existed,  in  perfect  sym- 
metry, two  whitish  patches  al)out  the  size  of  a  two-franc  piece, 
composed  of  an  aggregation  of  a  large  number  of  granulations 
identical  with  the  preceding.  Sections  of  the  organs  revealed 
an  immense  number  of  similar  granulations  scattered  in  the 
cortical  substance,  and  to  a  less  degree  in  the  pyramidal  portion. 
It  was  calculated  that  each  kidney  contained  from  300  to  400  of 
these  granulations.     ("Gaz.  Ilebd.,"  x.  p.  39.) 


CHAPTER   XIII. 


ENTOZOA  IN  THE  KIDNEYS. 


The  parasitic  worms  which  infest  the  kidneys  are:  Echinococ- 
cus  hominis  or  hydatid,  Bilharzia  hcematobia,  Filaria  sanguinis 
hominis,  Fentastoma  denticulatum,  and  Strongylus  gigas.  The  first 
named  is  by  far  the  most  common  in  these  latitudes ;  the  second 
is  the  most  common  in  Egypt,  Cape  of  Good  Hope,  and  certain 
other  hot  countries;  the  last  two  are  of  extreme  rarity.  Some- 
times intestinal  worms  wander  into  the  kidneys  and  urinary 
passages  [erratic  worms) ;  and  in  some  notable  instances,  objects 
which  were  not  parasites  at  all,  or  which  were  parasites  wholly 
foreign  to  the  human  body,  have  been  described  and  figured  as 
genuine  parasites  of  the  urinary  organs  [spurious  worms). 


Fig.  69. 


I.— HYDATIDS  IN  THE  KIDNEY. 

[Echinococcus  Hominis.) 

Hydatids  in  the  kidneys  are  comparatively  rare;    they  are 
much  less  common  than  hydatids  in  the  liver  and  even  in  the 
lungs ;  they  are  more  frequent  than  hydatids  in 
the  other  organs  and  tissues  of  the  body.^ 

JSTatural  History. — A  hydatid  tumor  consists 
of  an  adventitious  outer  capsule,  composed  of 
fibrous  tissue,  which  is  organically  connected 
with  the  texture  of  the  organ  in  which  it  is  situ- 
ated. Within  this,  and  unconnected  with  it  ex- 
cept by  contact,  lies  the  hydatid  cyst  itself.  This 
latter  varies  in  size  from  a  walnut  to  an  adult's 
head.  The  cyst-wall  varies  in  thickness  accord- 
ing to  the  size  of  the  cyst,  from  about  a  line  to 
a  tenth  of  a  line  or  less,  and  is  composed  of  an 
opalescent  tremulous  substance  resembling  boiled 
white  of  egg.  When  examined  more  closely  it  is 
found  to  have  a  laminated  structure  (Fig.  69),  and 
to  be  composed  of  an  immense  number  of  thin  lamellae  or  layers, 
which,  under  the  microscope,  exhibit  a  perfectly  homogeneous 

^  Davaine  gives  the  following  rough  approximations  of  the  relative  frequency 
of  h3-datids  in  the  different  organs  and  tissues : 

Liver 166 


Wall  of  a  hydatid 
cyst,  showing  the  la- 
minated structure  — 
not  magnified.  [After 
Davaine.] 


Lungs  . 
Kidneys 
Pelvis  . 
Brain     . 


Osseous  system 
Parietes  of  the  body 
Heart 
Orbit      . 


NATURAL     III  STORY, 


559 


structure.  Within  the  cavity  of  the  cynt  a  uuriiljor  of  fiecondary 
or  daughter  cysts  float  freely  in  a  watery  saline  fluid,  which  is 
devoid  of  albumen.'  The  daughter  cysts  vary  in  size  from  an 
orange  to  a  pea  or  pin's  head  :  they  may  be  even  much  smaller 
than  this,  and  require  a  microscope  for  their  detection.  A 
mother  cyst  may,  however,  be  barren  :  that  is,  contain  only  fluid 
contents;  but  this  is  rare.  More  commonly  twenty,  thirty,  a 
hundred,  or  even  many  thousand  secondary  cysts  float  within  it. 
The  structure  and  attributes  of  the  secondary  cysts  are  identical, 
in  every  respect,  with  those  of  the  parent;  and  their  walls  display 
the  same  characteristic  lamination. 

Sometimes  this  constitutes  the  entire  anatomy  of  a  hydatid 
cyst;  but  as  a  general  rule  additional  structures  are  found, 
which  indicate  a  more  advanced  phase  of  development :  these 
are  :  a  germinal  membrane  lining  the  interior  of  the  cyst,  and 
certain  minute  animalcules  growing  therefrom  which  are  termed 
echinococci  [scolices  or  tcenia- heads). 


Human  echinococci.  A  A  group  of  ecljjnococci,  still  adhering  to  the  germinal  membrane  by  their 
pedicles,  magnified  -lO  times  B.  An  echinococcus  magnified  107  times  ;  the  head  is  invaginated  in  the 
caudal  vesicle  ;  a  pedicle  is  attached  to  it.  0.  The  same  compressed ;  the  head  retracted,  the  suckers 
and  the  hooks  are  seen  in  the  interior.  D.  Echinococcus  magnified  107  times  ;  the  head  is  protruded 
from  the  caudal  vesicle.    B.  Crown  of  hooks  magnified  350  times      [After  Davaine  ] 

The  germinal  membrane  is  a  thin,  transparent,  homogeneous, 
(unlaminated)  tough  membrane,  which  forms  an  interior  sac 
closely  applied  to  the  inside  of  the  hj^datid  vesicle.  "When 
detached  and  emptied  it  shows  a  tendency  to  contract  and  curl 
on  itself  in  a  peculiar  manner. 

The  echinococci  (Fig.  70)  are  minute  ovoid  animated  beings, 
just  visible  to  the  naked  eye.     When  magnified  they  are  found 


^  This  is  not  strictly  correct.     I  have  twice  detected  a  not  inconsiderable  trace 
of  albumen  in  the  fluid  of  hydatid  cysts  of  the  liver. 


560 


HYDATIDS    IN    THE    KIDNEY, 


Fig.  71. 


to  consist  of  a  head  resembling  that  of  a  tapeworm,  provided 
with  four  suckers  and  a  double  crown  of  hooks  (E).  When  the 
head,  is  stretched  out  (D)  it  is  seen  to  be  connected  by  a  short 
thick  neck  to  a  "  caudal  vesicle,"  which  is  somewhat  larger  than 
the  head.  The  head  is  generally  retracted  within  this  caudal 
vesicle ;  and  then  the  little  body  assumes  a  spheroidal  iigure 
with  the  crown  of  hooks  in  its  interior  (B  C), 

The  echinococci  are  developed  on,  or  rather  in,  the  germinal 
membrane.  They  grow  in  groups  of  six  to  ten 
individuals,  and  are  at  first  encapsuled  in  the 
substance  of  the  germinal  membrane.  As  they 
increase  in  size  they  burst  through  their  capsule, 
and  are  then  found  attached,  each  by  a  short 
stalk  or  pedicle,  to  the  germinal  membrane 
(A).  By-and-by  they  break  loose  from  this 
attachment  and  float  at  large  in  the  hydatid 
vesicle,  sometimes  with  a  portion  of  their  stalks 
still  adherent. 

Both  the  echinococci  and  the  germinal  mem- 
brane are  liable  to  perish  (from  inflammation 
or  some  other  cause),  and  then  only  scattered 
hooks  or  shreds  of  membrane  are  found  floating 
in  the  turbid  contents  of  the  hydatid  vesicle. 

A  marvellous  light  has  been  thrown  in  recent 
years  on  the  zoological  position  of  these  w^orms, 
chiefly  by  the  researches  of  Siebold  and  Van 
Beneden.  It  has  been  ascertained  that  the 
hydatid  worm  found  in  man^  constitutes  the 
encysted  phase  in  the  development  of  a  very 
minute  tapeworm  which  infests  the  dog. 

The  tapeworm  in  question  (Fig.  71)  is  the 
Tcenia  echinococcus  of  Siebold  [Tcenia  nana  of 
Van  Beneden).  Th^  entire  adult  animal  is  so 
small  that  it  scarcely  exceeds  the  size  of  a 
millet-seed.  It  consists  of  but  three  segments, 
of  which  only  the  last  is  fruitful.  When  this 
segment  arrives  at  maturity  it  is  cast  oflT  and  a 
new  one  developed  in  its  place.  Myriads  of 
these  worms  are  sometimes  found  in  the  intes- 
tines of  the  dog,  and  their  eggs  are  discharged  in  countless 
numbers  with  the  excrements.  The  eggs  so  discharged  are 
scattered  far  and  wide ;  and  some  of  them  find  their  way  with 
the  food  into  the  stomachs  of  men  and  other  creatures  suitable 
for  their  further  development.  Arrived  there,  the  embryo  is 
liberated;    and,  after   penetrating   the    mucous   membrane,  it 


'/(ii. 


ei 


r 


/ 


Tasnia  echinococcus, 
magnified  22  times  — 
[After  Van  Beneden.] 


The  same  species  infests  the  pig,  monkey,  sheep,  and  ox. 


MORBID    ANATOMY.  561 

burrows  its  way,  or  is  carried  by  the  blood  current,  to  some 
distant  organ,  where  it  is  arrested.  Having  thus  lodged  itself, 
it  presently  reappears  as  a  hydatid  vesicle,  in  which,  finally,  are 
developed  the  echinococci  as  before  explained.  Dogs  in  their 
turn  become  infested  with  the  corresponding  tfenia  by  feeding 
on  the  oftal  of  slaughtered  sheej),  pigs,  etc.,  which  had  been 
infested  with  hydatids.  The  ecliinococci  therein  contained 
develop  in  their  intestines  into  the  taenia  echinococcus :  and 
so  the  circle  of  transformation  and  development  recommences.^ 

In  the  records  of  medicine  may  be  found  some  seventy  or 
eighty  instances  in  which  hydatids  existed  in  the  kidney  or 
were  passed  by  the  urethra.  In  a  number  of  these,  the  fact  is 
simply  mentioned ;  but  in  sixty-three  cases  some  fuller  details 
are  communicated,  and  from  an  analysis  of  these  the  following 
account  is  drawn  up. 

It  is  necessary  to  remark  that  when  hydatids  are  discharged 
by  the  urethra,  it  may  be  assumed  as  almost  certain  that  they 
are  derived  from  a  cyst  situated  in  the  kidney.  In  the  great 
majority  of  the  cases,  proof  of  this  was  obtained  either  from  the 
examination  of  the  body  after  death,  or  from  the  plain  indica- 
tion of  the  symptoms  during  life.  In  some  cases,  however,  this 
w^as  not  so;  and  it  remained  opened  to  conjecture  whether  the 
parent  cyst  was  not  situated  in  the  vicinit}^  of  the  ureter  or 
bladder,  and  opened  directly  into  those  channels.  Such  an 
occurrence  seems,  however,  extremely  rare,  and  I  have  only 
been  able  to  find  one  instance  in  which  actual  proof  of  this  was 
obtained.^ 

Morbid  Anatomy. — The  left  kidney  is  more  frequently  the 
seat  of  hydatids  than  the  right :  out  of  42  cases,  the  left  kidney 
was  affected  22  times  and.  the  right  18  times,  and  both  organs 

'  For  further  information  and  details  of  experiments  see — Gervais  and  Van 
Beneden,  t.  ii.  p.  270  et  seq.  ;  Davaine,  loc.  cit.,  Synopsis,  7  and  24;  and  Siebold's 
memoir  on  tape  and  cystic  worms,  bound  with  the  second  vol.  of  Kiichenmeister's 
Manual  of  Parasites.     Syd.  Soc.'s  Translation. 

^  In  the  Med.  Times  and  Gaz.  for  1855,  i.  p.  161,  a  case  is  referred  to,  on  the 
authority  of  Mr.  Birkett,  in  which  hydatids  were  withdrawn  by  catheter  from  the 
bladder.  After  death  a  large  hydatid  tumor  was  found  between  the  bladder  and 
rectum,  pressing  upon  the  neck  of  the  former.  Rayer  (loc  cit.,  iii.  354,  foot-note) 
relates  an  instance  in  which  a  hydatid  tumor  in  the  left  iliac  fossa  opened  into  the 
rectum,  with  expulsion  of  hydatid  vesicles  with  the  stools  and  discharge  of  pus 
and  gas  by  the  urethra.  He  cites  another  (p.  554,  note),  in  which  hydatid^  were 
passed  by  stool,  and  afterwards  a  large  hydatid  escaped  by  the  urethra  ;  but  there 
is  no  information  as  to  the  seat  of  the  c^'st,  the  patients  having  recovered.  There 
is  another  case,  recorded  by  Mr.  Fynney  in  an  appendix  to  the  second  vol.  of  the 
Memoirs  of  the  Medical  Societj''  of  London,  in  which  hydatids  were  passed  with 
the  urine  from  a  ejst  which  in  all  probability  existed  between  the  bladder  and 
rectum.  Immediately  before  the  discharge  of  the  vesicles  the  patient  felt  some- 
thing give  way  in  the  neighborhood  of  the  bladder.  The  patient  died  in  a  few 
weeks  ;  but  the  exact  seat  of  the  cyst  was  not  verified  by  post-mortem  inspection. 
Cases  of  this  class  can  be  distinguished  from  renal  hydatids  by  manual  examina-- 
tion  through  the  rectum  or  vagina. 

36 


562  HYDATIDS    IN    THE    KIDNEY. 

together  only  twice.  The  less  liability  of  the  right  kidney 
depends  probablj^,  as  Beraud  suggests,  on  the  larger  bulk  of 
the  liver  intercepting  a  greater  proportion  of  the  embryos 
which  travel  from  the  intestine  rightwards,  than  the  smaller 
bulk  of  the  spleen  does  of  those  which  travel  leftwards.  In  rare 
instances,  hydatids  have  been  found  in  the  liver  and  other 
organs  as  well  as  in  the  kidney. 

As  a  rule,  the  cyst  is  lodged  in  the  substance  of  the  kidney; 
sometimes,  however,  between  the  capsule  and  the  gland.  As 
the  cyst  grows  it  encroaches  more  and  more  on  the  renal  tissue, 
and  eventually  may  entail  total  destruction  of  the  organ.  It 
forms  a  roundish,  elastic,  fluctuating  tumor,  projecting  from  the 
surface  of  the  kidney,  and  varying  in  size  from  an  egg  to  an 
adult's  head. 

The  cyst  has  a  natural  tendency  to  make  its  way  toward  the 
pelvis  of  the  kidney,  and  discharge  its  contents  by  the  ureter. 
When  it  is  situated  in  the  pyramidal  portion,  this  event  takes 
place  early,  before  the  cyst  has  attained  any  great  dimensions : 
but,  when  situated  in  the  cortical  part,  or  beneath  the  capsule, 
the  cyst  may  exist  for  years,  and  grow  to  a  large  size,  before  it 
bursts  into  the  infundibula.  It  may  even  not  burst  at  all ; 
and,  still  more  rarely,  it  may  penetrate  upward  into  the  chest 
and  be  evacuated  through  the  bronchi,  or  open  into  the  intes- 
tines and  be  discharged  by  stool.  Sometimes,  after  opening  in 
one  direction,  it  eft'ects  a  second  opening  in  another  direction. 
In  no  instance  on  record  has  the  cyst  burst  into  the  peritoneum. 
The  following  table  exhibits  the  relative  frequency  of  these 
various  modes  of  opening  in  our  63  cases : 

The  cyst  opened  into  the  :^ 

Pelvis  of  kidney       .         .         .         .  in  47  cases  "] 

Pelvis  of  kidney  and  lungs      .         .  1     "        |     Hydatids  discharged  by 

Pelvis  of  kidney  and  intestines        .  3     "        f                the  urethra. 

Pelvis  of  kidney  and  stomach           .  1     "       J 

Lungs  alone                        .         .         .  in  1  case  |    ^^  hydatids  discharged 

Did  not  open  at  all  ....  I    [\       \            by  the  urethra. 

Opened  artmcially    ....  J    "      J               '' 

Hydatid  cysts  of  the  kidney,  like  hydatid  cysts  elsewhere,  are 
liable  to  certain  accidents.  They  may  contract  adhesions  to 
surrounding  parts;  occasion  inflammation  and  abscess  in  their 
vicinity,  and  the  cyst  may  burst  into  such  an  abscess.     The  cyst 

1  No  authenticated  cases  exist  of  a  hydatid  cyst  of  the  kidney  opening  in  the 
loins.  Payer  (iii.  578)  mentions  two  examples  of  hydatid  cysts  in  the  loins,  which 
suppurated  and  burst  externally  in  the  lumbar  region.  He  seems  to  infer  that  the 
cysts  in  these  cases  were  connected  with  the  kidney  :  both  ended  in  recovery.  It 
is  more  probable,  however,  that  the  cysts  were  lodged  superficially  in  the  muscular 
tissue  of  the  lumbar  region.  In  a  later  case  of  this  kind  which  ended  fatally,  it 
was  ascertained  post-mortem  that  the  cyst  lay  surperficial  to  the  kidney  and  un- 
connected with  it. 


ILLUSTRATIVE    CASES.  563 

itself  may  suppurate;  or  it  may  perish,  and  its  gerrrihial  raeru- 
brane  and  echinococci  be  destroyed;  the  fluid  it  contains  may 
then  be  absorbed,  and  the  whole  crumple  up  into  a  hard  de- 
pressed nodule,  whicPi  henceforth  lies  dormant  and  obsolete. 
This  obsolescence  may  ensue  without  bursting  of  the  sac,  or  it 
may  follow  complete  evacuation  of  its  contents.  The  contrac- 
tion and  obsolescence  of  a  hydatid  cyst  are  accompanied  by 
deposition  of  a  whitish  cretaceous  and  sebaceous  material  be- 
tween it  and  the  adventitious  capsule,  and  within  its  own  cavity. 
This  deposit  was  formerly  erroneously  supposed  to  be  of  a 
tuberculous  nature.  Under  the  microscope  it  is  found  to 
consist  of  amorphous  phosphate  of  lime,  crystals  of  triple  phos- 
phate, cholesterine  plates,  and  fattj^  granules.  Amid  this 
debris,  echinococci  hooks  and  shreds  of  laminated  membrane 
may  be  found. 

Hydatid  cysts  are  also  liable  to  external  violence,  especially 
when  they  form  a  palpable  tumor  in  the  flank.  A  blow  or 
fall  has  in  more  than  one  instance  been  the  apparent  cause  of 
the  bursting  of  the  sac  into  the  pelvis  of  the  kidney ;  and  the 
patient  has  dated  his  symptoms  from  the  occurrence  of  some 
such  accident. 

The  opening  of  the  cyst  into  the  pelvis  of  the  kidney  is  soon 
followed  by  the  passage  of  secondary  or  daughter  vesicles  along 
the  ureter  into  the  bladder,  from  which  they  are  expelled  sooner 
or  later  with  the  urine. 

The  first  of  the  two  following  cases  illustrates  the  ordinary 
mode  of  evacuation  by  the  ureter;  the  second  by  the  ureter 
and  lungs  : 

Case  1.  Hydatid  vesicles  voided  by  the  urethra,  at  intervals,  for  twenty 
years,  with  symptoms  resembling  nephritic  colic.  Hydatid  cyst  found  in  the 
left  kidney  (Chopart,  loo.  cit.,  p.  78). — A  young  lady  of  25  was  seized 
with  a  violent  pain  in  the  left  lumbar  region,  with  all  the  symptoms  of 
nephritic  colic.  There  was  difficulty  of  micturition,  tension,  and  ten- 
derness of  the  abdomen.  The  bladder  was  full  of  urine,  but  some 
obstruction  prevented  its  flow,  though  there  was  constant  desire  to  pass 
it.  In  the  course  of  the  night  the  emptying  of  the  bladder  was  efiected, 
with  discharge  of  a  large  number  of  hydatids.  Wlien  the  discharged 
vesicles  were  examined  on  the  following  morning,  the  majority  were 
found  ruptured,  and  consisted  of  loose  membranes  only;  some  were 
entire,  and  contained  a  turbid  fluid.  The  patient  was  relieved  b.y  the 
evacuation ;  but  the  pain  returned  again  in  less  severity  two  days  after. 
This  pain  commenced  in  the  kidney,  and  when  it  diminished  in  that 
organ  it  increased  at  different  points  in  the  course  of  the  ureter,  and 
became  more  acute  at  the  entrance  of  this  canal  into  the  bladder. 
When  the  hydatids  had  reached  the  bladder  the  pain  in  all  these  parts 
was  replaced  by  a  sort  of  lassitude. 

The  patient  stated  that  she  had  been  subject  to  similar  attacks  for 
twenty  years ;  and  that  they  always  terminated  in  a  discharge  of  little 


564  HYDATIDS    IN    THE    KIDNEY. 

bladders  full  of  water.  Some  of  these  were  as  big  as  a  pigeon's  egg  ; 
others  were  much  smaller;  the  latter  always  came  away  first.  The 
attacks  recurred  at  irregular  intervals ;  she  was  sometimes  six  months, 
a  year,  two;  or  even  three  years  without  an  attack.  In  some  of  the 
attacks  the  efforts  at  micturition  would  be  long  unavailing,  until  at 
length,  by  increased  effort  and  pressure  on  the  belly,  the  hydatids  would 
shoot  out  with  a  sort  of  noise,  and  then  the  urine  followed  in  full  stream. 
Four  years  later,  the  patient  died  ;  it  is  not  stated  from  what  cause. 
The  left  kidney  was  found  converted  into  a  thick  and  firm  hydatid  sac, 
filled  with  vesicles.  The  pelvis  and  ureter  were  greatly  dilated.  The 
right  kidney  was  healthy. 

Case  2.  Hydatid  cyst  of  the  right  kidney,  which  opened  first  into  the 
ureter  and  subsequently  into  the  right  lung.  Hydatid  vesicles  discharged 
with  the  urine  and  by  coughing  (Beraud,  loc.  cit.,  p.  63). — Madame  B., 
set.  54,  had  experienced,  for  several  months,  pains  in  the  right  lumbar 
region  and  occasional  difficulty  of  micturition  ;  otherwise  the  health  was 
good. 

On  August  30,  1851,  she  was  suddenly  seized  with  such  violent  pain 
in  the  right  kidney  that  she  was  obliged  to  be  carried  home.  M.  Fiaux, 
who  was  called  to  the  case,  found  extreme  distention  of  the  bladder ;  a 
catheter  was  introduced,  and  the  urine  withdrawn  presented  nothing 
unusual.  The  patient  passed  a  good  night,  and  was  quite  restored  in  a 
couple  of  days. 

On  September  15th,  she  went  to  St.  Denis,  where  she  was  seized  with 
the  same  symptoms  as  before.  She  succeeded,  after  great  efforts,  in 
expelling  by  the  urethra  a  little  membranous  vesicle  as  big  as  a  pigeon's 
egg,  and  immediately  afterwards  she  passed  abundance  of  water,  and 
was  relieved. 

On  the  26th,  the  pains  returned  ;  they  commenced  in  the  right  lumbar 
region,  and  radiated  towards  the  pelvis  and  the  right  thigh.  She  tried 
to  pass  water  several  times  during  the  night,  without  success.  The 
bladder  reached  almost  to  the  umbilicus.  A  large  quantity  of  clear 
urine  was  withdrawn  by  catheter  with  immediate  relief. 

From  the  8th  to  the  23d  of  October,  retention  of  urine  recurred  on 
three  occasions,  and  the  urine  withdrawn  did  not  present  any  pecu- 
liarities. 

On  November  2d,  the  pain  in  the  kidney  returned  with  great  severity ; 
it  mounted  to  the  liver  and  descended  along  the  ureter  to  the  thigh  ; 
there  was  thirst,  hot  skin,  with  tenderness  and  meteorism  of  the  abdo- 
men. The  patient  had  passed  water  several  times  during  the  night,  but 
in  very  small  quantities.  The  urine  was  turbid,  with  a  glairy  deposit  at 
the  bottom  of  the  vessel.  From  this  date  to  the  22d,  the  pain  dimin- 
ished ;  the  urine  continued  turbid,  and  contained  pus. 

On  the  24th,  the  patient  had  a  violent  rigor,  and  the  renal  pain  became 
more  severe  than  ever.  Vomiting  occurred  several  times  during  the 
night,  and  three  or  four  liquid  stools  were  passed.  She  also  voided  urine 
several  times.  M.  Fiaux  now  observed,  for  the  first  time,  in  the  urine, 
shreds  of  membrane  having  the  characters  of  hydatids.  On  examining 
the  right  flank,  an  oblong  tumor  was  found  below  the  liver,  apparently 
united  to  it,  extending  to  the  iliac  fossa  and  having  a  breadth  of  about 


MORBID    ANATOMY.  565 

4]  inches.  The  tumor  was  hard,  and  tender  on  pressure ;  no  loop  of 
intestine  passed  in  front  of"  it ;  the  lumbar  region  behind  jjresented  a  tol- 
erably prominent  bulging.  It  was  no  longer  doubtful  that  this  was  a 
hydatid  tumor  of  the  right  kidney  in  a  state  of  inflammation. 

From  this  time  hydatid  fragments  continued  to  be  discharged  with 
the  urine  from  time  to  time,  and  the  lumbar  fulness  became  more  pro- 
nounced. 

On  the  22d  of  December,  under  the  advice  of  Gendrin,  steps  were 
taken  to  open  the  tumor,  and  several  caustic  issues  were  established  on 
the  front  of  it. 

But  on  the  2d  of  January  violent  pain  set  in  at  the  base  of  the  right 
lung,  with  cough,  mucous  expectoration,  and  fever.  Frequent  shivering 
occurred  the  next  day,  and  the  pain  and  fever  continued. 

January  7. — The  oppression  was  increased.  Violent  fits  of  coughing 
occurred,  with  abundant  purulent  expectoration,  of  a  fetid  urinous  odor  ; 
and  this  was  mingled  with  membranes  similar  to  those  discharged  with 
the  ui'ine.  She  continued  to  cough  up  hydatid  shreds  and  urinous  pus 
and  to  become  gradually  weaker  until  January  22d,  when  she  died  in  a 
fit  of  suffocation,  after  having  discharged  seven  or  eight  hydatids. 

Autopsy. — The  small  intestine  was  thrust  to  the  left ;  the  ascending 
colon  bordered  the  tumor,  and  was  intimately  connected  therewith  in  its 
lower  two-thirds.  The  right  lung  was  indurated  at  its  base,  and  united 
to  the  diaphragm.  Behind  the  cyst  was  a  purulent  collection,  as  large 
as  an  orange,  which  communicated  with  the  cavity  of  the  cyst.  The 
liver,  left  lung,  and  stomach  were  healthy. 

The  tumor  was  found  adherent  to  the  lower  surface  of  the  liver.  It 
was  constituted  by  the  right  kidney,  Avhich  was  converted  into  a  sac  as 
large  as  a  child's  head.  Few  remains  of  the  renal  tissue  were  found. 
On  cutting  open  the  sac,  it  was  found  to  communicate  by  two  distinct 
openings  with  the  dilated  pelvis  of  the  kidney  and  the  abscess.  The 
latter  again,  which  occupied  the  vault  of  the  diaphragm  behind  the 
liver,  communicated  by  a  perforation  through  the  diaphragm  with  a 
ragged  cavity  in  the  base  of  the  right  lung.  All  these  cavities,  with 
the  pelvis  of  the  kidney,  the  bladder,  and  the  bronchi,  contained  a 
purulent  fluid  and  numerous  hydatid  vesicles. 

Ill  rare  cases,  the  secondary  cysts  contain  a  tertiary  series 
(granddaughter  cysts).  Baillie  mentions  such  an  instance  in  the 
body  of  a  soldier,  whose  kidney  was  found  to  contain  a  large 
hydatid  cyst.  Some  of  the  secondary  cysts  in  this  instance 
merely  contained  fluid ;  others  contained  small  vesicles  floating 
in  their  interior.^ 

Occasionally,  crystals  of  uric  acid  have  been  found  adhering 
to  the  expelled  hydatids ;  and  in  Mr.  Barker's  case,  to  be  pres- 
ently related,  Mr.  Queckett  found  in  the  interior  of  some  of 
the  cysts  crystals  of  triple  phosphate,  uric  acid,  and  oxalate  of 
lime.  In  four  cases  calculi  were  found  with  the  hydatids  in  the 
kidney  or  bladder;  or  were  passed  by  the  urethra. 

1  Baillie,  Morbid  Anat.,  5th  eel.,  p.  294. 


566  HYDATIDS    IN    THE    KIDNEY. 

The  Symptoms  differ  essentially  according  as  the  cyst  has 
forced  a  passage  for  its  contents  into  the  pelvis  of  the  kidney, 
or  elsewhere,  or  still  maintains  its  integrity.  In  the  latter  case 
the  cyst  remains  wholly  latent  until  it  attains  sufficient  bulk  to 
form  a  palpable  tumor  in  the  flank.  As"  the  tumor  grows,  it 
displaces  the  viscera  in  its  neighborhood,  generally  without 
further  mischief;  but  sometimes  inflammatory  adhesions  or 
suppuration  take  place  in  its  vicinity  and  occasion  intercurrent 
attacks  of  pain  and  feverishness.  In  eighteen  out  of  our  sixty- 
three  cases,  tumor  in  the  side  was  discernible  during  life.  It 
varied  in  size  from  an  orange  to  an  adult's  head,  and  presented 
a  rounded  form  and  an  elastic  feel.  In  some  instances  fluctua- 
tion was  distinctly  perceived  in  it;  in  others  obscurely;  in  others 
not  at  all.  The  peculiar  thrill  characteristic  of  hydatid  tumors 
(hydatid  fremitus)  was  observed  only  in  a  few  instances.  In 
order  to  evoke  this  sign,  the  fingers  of  the  left  hand  should  be 
laid  upon  the  tumor,  and  tapped  sharply  with  the  fingers  of  the 
right,  A  thrill  is  then  communicated  to  the  overlaid  fingers, 
which  has  been  compared  to  the  vibrations  of  a  repeater  watch 
held  in  the  hand.  A  similar  sensation  is  communicated  to  the 
ear  when  the  stethoscope  is  applied  and  the  tumor  tapped  with 
the  fingers.^  Sometimes  the  fremitus  is  absent  under  conditions 
which  appear  favorable  to  its  production.  In  a  case  reported 
by  Livois  (cited  by  Beraud)  even  Rayer  was  unable  to  detect 
anything  beyond  ordinary  fluctuation,  and  diagnosed  a  hydro- 
nephrosis. After  death  the  kidney  was  found  converted  into 
an  enormous  hydatid  sac  containing  multitudes  of  secondary 
vesicles,  varying  from  the  size  of  a  grain  of  millet  to  a  hen's  egg. 

The  topographical  characters  of  the  tumor  agree  with  those 
of  renal  tumors  in  general.  The  colon  is  usually  found  in 
front  of  the  intumescence :  but  it  is  important  to  know  that 
this  is  not  invariable.  Beraud  communicates  a  case  from 
Nelaton's  clinique,  in  which  the  descending  colon  ran  along  the 
outside  of  a  hydatid  tumor  of  the  left  kidney  :  in  Fiaux's  case, 
already  related  (p.  564),  the  ascending  colon  coursed  along  the 
inner  border  of  the  tumor,  and  no  intestine  separated  it  from 
the  abdominal  parietes. 

When  the  cyst  bursts  into  the  pelvis  of  the  kidney,  the  escape 
of  its  contents  by  the  urethra  constitutes  a  capital  symptom. 
This  may  occur  with  or  without  symptoms  referrible  to  the 
renal  region  (tumor,  nephritic  colic,  etc.).  Entire  vesicles 
mixed  with  broken  ones  are  usually  voided;  in  other  cases  only 
fragments  are  passed,  or  a  milky  detritus  in  which  echinococci 

1  The  history  and  theory  of  the  hydatid  fremitus  may  be  found  discussed  at 
length  (with  an  account  of  Davaine's  experiments)  in  Meissner's  Beitrasje  zur 
Lehre  von  dem  Vorkommen  des  Echinococcus,  etc.  Schmidt's  Jahrb.,  Bd.  116, 
S.  183. 


SYMPTOMS.  567 

hooks,  laminated  shreds,  and  oil  particles  rna^'  be  detected  by 
the  microscope. 

The  discharge  of  vesicles  takes  place  in  paroxysmal  attacks 
at  wholly  irregular  intervals.  In  exceptional  cases,  only  one 
paroxj'sm  is  experienced,  during  which  the  cyst  is  seemingly 
entirely  evacuated,  and  then  finally  contracts.  In  the  great 
majority  of  cases,  however,  the  first  attack  is  succeeded  by 
many  others.  The  interval  between  them  may  be  a  few  weeks, 
or  a  few  months,  or  many  years.  In  a  case  reported  by  Tomo- 
witz,  the  second  attack  occurred  three  years  after  the  first.  In 
Quinquerez's  case,  seven  years  elapsed  between  the  first  and 
second  discharge  of  hydatids ;  then  the  attacks  followed  each 
other  more  frequently,  at  intervals  of  one  or  more  years, 
for  ten  years;  in  the  last  year  they  recurred  every  four  or  six 
weeks. 

An  attack  is  usually  ushered  in  by  sharp  pain  in  the  loin, 
sometimes  with  a  sensation  as  of  something  giving  way  inter- 
nally. The  pain  shoots  down  along  the  ureter  to  the  inside  of 
the  thigh.  It  may  be  attended  with  rigors,  sickness,  and  hic- 
cough— though  this  is  rare ;  then  follow  colicky  spasm  in  the 
course  of  the  ureter,  indicating  the  descent  of  vesicles  along 
that  canal — sometimes  aggravated  by  suppression  of  urine  and 
retraction  of  the  testicle.  These  symptoms  continue  a  few 
hours  or  several  days,  and  they  commonly  cease  suddenly,  often 
with  a  feeling  as  if  something  had  dropped  into  the  bladder. 
The  urethra  is  next  forced,  and  new  symptoms  arise — retention 
of  urine,  excessively  frequent  desire  to  pass  water,  with  severe 
pain  extending  to  the  end  of  the  penis.  When  the  vesicles  are 
expelled,  relief  follows.  The  number  of  vesicles  discharged 
during  an  attack  varies  from  one  or  two  to  several  dozens. 
The  urine  is  often  tinged  with  blood  or  mixed  with  pus.  The 
force  required  to  effect  the  final  expulsion  is  sometimes  sufficient 
to  propel  the  vesicle  a  considerable  distance  with  an  audible 
thud. 

The  paroxj^sms  are  sometimes  determined  by  some  evident 
exciting  cause,  such  as  a  blow  or  fall,  or  by  horse  or  carriage 
exercise.  In  Zinkeisen's  case  the  attacks  usually  followed  the 
use  of  spirits  and  strong  cofiee.^ 

After  each  discharge  of  hydatid  vesicles  the  tumor  (if  any 
exist)  may  subside  sensibly.  On  the  other  hand,  rapid  enltirge- 
ment  of  the  tumor,  from  distention  of  the  pelvis  with  accumu- 
lated urine,  may  follow  the  impaction  of  a  vesicle  in  the  n refer. 
Repeated  discharges  occasion  dilatation  of  the  passages,  and 
enable  the  patient  to  void  larger  vesicles  with  less  pain. 

1  Schmidt's  Jahrb.,  Bd.  116,  S.  290. 


568  HYDATIDS    IN     THE    KIDNEY. 

The  following  examples  illustrate  the  eccentric  course  and 
usual  symptoms  of  renal  hydatids  : 

Case  3.  .  Repeated  discharge  of  hydatid  vesicles  with  the  urine;  tumor 
in  the  left  lumbar  region — final  recovery  (Lettsom,  "  Memoirs  of  the  Medi- 
cal Societies  of  London,"  vol.  ii.  p.  32). — A  gentleman,  aged  32,  was 
thrown  off  his  horse  in  February,  1780,  and  received  an  injury  in  the 
lumbar  region.  This  was  followed  by  considerable  hsematuria.  In  a 
fortnight  all  the  consequences  of  his  fall  had  disappeared;  but  in  the 
following  June  he  spat  blood ;  this  also  passed  rapidly  away.  Three 
years  later,  he  was  seized  with  shivering  and  a  violent  pain  in  the  left 
lumbar  region.  A  few  days  after,  he  perceived  an  enlargement  in  the 
hypochondrium.  This  increased  gradually  until  February,  1784.  After 
the  first  month  the  tumor  was  so  little  painful  that  he  was  enabled  to 
take  a  journey  of  130  miles  to  London  to  consult  Dr.  Lettsom. 

A  fluctuating  tumor  as  large  as  an  infant's  head  was  detected  in  the 
left  hypochondrium,  extending  from  the  spine  to  the  umbilicus  and  from 
the  ribs  to  the  os  innominatum. 

As  the  swelling  augmented  the  pain  increased,  and  the  patient  suf- 
fered considerably  from  the  action  of  walking  and  from  motion  in 
general.  At  length  (February  20th)  some  difficulty  in  making  water 
was  experienced,  and  for  many  hours  there  was  a  total  obstruction  of 
urine.  The  same  night  there  was  great  pain  with  violent  rigors ;  but 
early  in  the  morning  the  patient  experienced  the  most  happy  relief  by 
the  discharge  of  a  large  quantity  of  thick  pus  with  the  urine,  which 
was  followed  the  next  day  by  the  escape  of  numerous  hydatids. 

In  a  few  days  the  tumor  subsided,  and  the  purulent  discharge  ceased  ; 
after  this,  he  continued  recruiting  his  health  for  nearly  a  fortnight,  when 
his  side  enlarged  again,  after  exercise  in  a  coach,  probably  by  a  large 
hydatid  stopping  up  the  ureter ;  rigors  and  strangury  succeeded  as 
before,  and  the  tumor  became  as  large  as  in  the  first  instance,  until  the 
latter  end  of  March,  when  he  experienced  a  second  discharge  in  every 
respect  like  the  former,  excepting  that  the  hydatids  were  larger. 

His  health  and  strength  again  returned,  until  his  side  filled  a  third 
time,  after  exercise  on  horseback,  and  continued  swelling  until  the  25th 
of  April,  when  he  was  again  relieved  by  a  third  discharge ;  the  hydatids 
now  passed  were  considerably  larger  than  those  of  the  preceding  attacks. 

The  passages  now  became  so  open,  that  he  frequently  discharged 
hydatids  after  walking  or  riding,  without  enlargement  or  pain  of  the 
side ;  or  if  he  felt  uneasy  or  perceived  a  tendency  to  tumescence,  by 
pressing  his  hand  upon  his  side  he  could  squeeze  the  vesicles  into  the 
bladder,  where  they  would  remain  some  time  before  they  were  dis- 
charged ;  but  the  hydatids  became  at  length  so  considerable  in  size  that 
it  was  with  great  difficulty  they  passed  the  urethra.  The  last  vesicle 
which  he  voided  (on  the  12th  of  July)  was  so  very  large  that  it  stopped 
up  the  urethra,  and  remained  in  it  for  a  considerable  time,  until  the 
weight  of  the  accumulated  urine  forced  it  away. 

The  earliest  hydatids  voided  burst  in  their  exit ;  and  they  gradually 
increased  in  magnitude  in  every  successive  discharge ;  the  first  which 
he  passed  were  not  bigger  than  the  skin  of  a  green  pea,  and  the  last 
about  the  size  of  a  pullet's  egg. 


ILI.USTKATI  VE    CASES.  569 

Since  this  last  discbarge  his  health  was  gradually  rtestabiished  ;  he 
was  able  to  enjoy,  without  the  least  inconvenience,  thereafter,  the  chase 
and  every  other  species  of  exercise  as  well  as  ever  he  did. 

Case  4.  Discharge  of  JiydatMs  by  the  urethra  hi,  periodical  paroxymiH 
occurring  yearly  for  a  period  of  tldrty-aeven  yearn  (Vigla,  ''  Bulletin  de  la 
Soci6te  Anatoniique,"  1838.  Cited  by  Beraud,  loc.  cit.,  p.  57 j.  —  A 
healthy  woman,  tet.  37,  had  suffered  from  her  infancy  with  her  present 
symptoms,  which  occur  in  annual  paroxysms.  Every  winter,  and  gen- 
erally in  the  month  of  January,  she  experiences  in  the  left  renal  region 
a  pain,  which  speedily  becomes  severe  and  forces  her  to  relinquish  her 
occupation.  There  is  no  fever  ;  nor  vomiting  ;  but  the  appetite  is  lost ; 
the  urine  remains  natural.  At  the  end  of  two  or  three  days  of  this  con- 
dition, she  voids  a  very  large  number  of  hydatids,  mingled  with  a  turbid 
urine.  This  emission  takes  place  two  or  three  times  a  day,  for  three  or 
four  days,  and  then  she  returns  to  her  ordinary  health.  Sometimes, 
but  very  rarely,  similar  attacks  occur  in  the  course  of  the  year,  but 
slighter ;  these  latter  consist  of  a  violent  pain  in  the  same  place,  not  last- 
ing more  than  two  or  three  hours,  at  the  end  of  which  an  emission  of 
urine  with  discharge  of  hydatids  ensues,  and  the  pains  disappear.  These 
slighter  attacks  have  never  recurred  more  than  once  or  twice  in  the 
same  year.  In  the  year  1828  one  of  the  annual  January  attacks  was 
observed  by  M.  Vigla.  The  prodromata — that  is  to  say,  the  pain  and 
uneasiness — were  accompanied  with  feverishness  ;  but  this  was  attributed 
to  a  coexisting  acute  pulmonary  catarrh.  At  the  end  of  four  days,  as 
usual,  the  emission  of  urine  charged  with  hydatids  commenced,  and 
continued  for  four  days.  The  quantity  of  vesicles  which  she  rendered 
was  enormous;  for  she  passed  urine  twice  or  thrice  on  each  of  these 
three  days,  and  every  time  from  40  to  50  large  hydatids  were  found  in 
the  urine,  without  counting  the  little  ones.  The  larger  ones  passed  the 
first,  but  ruptured  and  empty;  the  largest  of  all  surpassed  the  size  of  a 
pigeon's  egg.  The  smaller  ones  were  voided  entire,  and  full  of  a  semi- 
transparent  fluid  ;  some  were  smaller  than  a  pea.  There  were  no 
symptoms  referrible  to  the  bladder. 

Case  5.  Hydatid  cyst  of  the  right  kidney ;  suspicion  of  pregnancy ;  dis- 
charge of  hydatid  vesicles  by  the  urethra  (Babington,  "Med.  Times  and 
Gaz.,"  1855,  i.  p.  160). — A  healthy  single  woman,  set.  27,  was  admitted 
into  Guy's  Hospital  on  February  8,  1854.  About  the  age  of  23  she 
was  one  day  kicked  in  the  abdomen  by  a  child  which  she  was  carrying 
upstairs.  The  kick  gave  her  much  pain,  and  on  the  night  following  she 
discovered  for  the  first  time  a  tumor  about  the  size  of  an  egg  in  her  right 
side.  The  tumor  gradually  increased,  and  in  the  course  of  a  year  became 
so  large  as  visibly  to  distend  the  abdf)raen.  About  this  time  the.  men- 
strual function  was  suspended,  and  the  increasing  size  of  the  abdomen 
caused  her  great  trouble,  by  exciting  suspicions  in  the  minds  of  her  rela- 
tives that  she  was  pregnant.  The  enlargement,  however,  continued 
beyond  the  usual  period  of  utero-gestation,  and  anxieties  as  to  the  nature 
of  the  disease  took  the  place  of  the  suspicious  alluded  to.  She  was  now 
sent  up  to  London  from  her  home  in  Oxfordshire,  and  was  admitted  into 
St.  Bartholomew's  Hospital  under  Dr.  Hue.  The  tumor  was  at  this 
time  stationary,  and  her  general  health  good.  After  a  few  weeks'  stay 
in  the  hospital  she  was  discharged,  and  returned  to  service,  where  she 


570  HYDATIDS    IN    THE    KIDNEY. 

continued  without  material  change  ia  her  condition  until  about  a  year 
prior  to  her  admission  into  Guy's  Hospital,  under  Dr.  Babington,  when 
she  began  to  pass  "skins  and  little  bladders,"  Avith  the  urine.  These 
bodies  continued  to  be  voided  afterwards  in  large  numbers.  Often  a 
vesicle  would  get  impacted  in  the  urethra,  and  require  to  be  pulled  out 
with  the  fingers.  At  first  neither  blood  nor  matter  was  ever  present  in 
the  urine.  About  two  weeks  before  admission,  however,  after  having 
been  confined  to  bed  for  several  days  with  intense  pain  in  the  side,  she 
suddenly  felt  a  sensation  as  if  something  burst  within  her,  and  shortly 
afterwards  matter  and  blood  began  to  escape  by  the  urethra.  The 
tumor  had  meanwhile  much  diminished  in  size,  and  at  the  time  of  her 
admission  there  was  no  visible  enlargement  of  the  abdomen.  During 
her  illness  she  had  lost  some  flesh,  but  still  retained  a  fairly  robust 
appearance. 

On  examination  of  the  abdomen,  a  large  mass  apparently  about  the 
size  of  a  foetal  head,  but  flattened,  was  easily  felt  in  the  right  hypochon- 
driac or  lumbar  region.  It  was  not  tender,  and  felt  firm.  The  patient 
remained  under  Dr.  Babington's  care  for  several  moaiths,  during  which 
vast  numbers  of  hydatid  vesicles  were  passed.  The  vesicles  varied 
much  in  size,  some  were  broken  and  others  whole.  The  urine  contained 
also  much  pus.  The  girl  somewhat  improved  in  health,  and  the  tumor 
became  decidedly  smaller  before  she  left  the  liospital ;  at  the  time  of 
her  discharge,  she  still  continued  to  void  occasionally  pus  and  hydatid 
vesicles. 

Case  6.  Frequent  discharge  of  hydatid  vesicles  by  the  urethra — ne- 
phritic colic  and  suppression  of  urine.  No  tumor  in  the  flanh  (Dr.  Barker, 
loc.  cit.,  p.  5). — A  young  man,  set.  28,  came  under  the  notice  of  Dr. 
Barker,  of  Bedford,  on  December  17,  1853.  He  was  suffering  from  a 
dull  aching  pain  in  the  loins,  particularly  on  the  left  side,  with  frequent 
desire  to  pass  urine,  and  slight  difficulty  in  voiding  it.  The  urine  was 
healthy.  On  the  22d  of  December  he  experienced  greater  difficulty 
than  ever  in  passing  urine  in  the  early  part  of  the  night,  and  for  some 
hours  he  was  unable  to  pass  a  single  drop.  Early  in  the  morning  he 
passed  four  little  hydatid  cysts  with  immediate  relief.  Subsequently 
he  recovered  sufficiently  to  follow  his  occupation  during  the  summer  of 
1854,  suffering  nothing  more  than  an  occasional  frequent  desire  to  void 
urine. 

On  September  10,  1854,  he  passed  six  cysts ;  but  with  less  pain  than 
on  the  previous  occasion — a  result  which  the  patient  attributed  to  taking 
10  drops  of  oil  of  turpentine,  which  had  been  recommended  to  him,  and 
which  greatly  increased  the  diuresis.  The  urine  after  the  passage  of  the 
cysts  was  tinged  with  blood. 

On  November  16th  he  passed  four  cysts.  The  passage  of  these  was 
preceded  by  severe  pain  in  the  left  kidney,  by  the  passage  of  several 
pieces  of  clotted  blood,  and  by  considerable  difficulty  in  voiding  urine. 
Indeed,  for  two  entire  days  he  passed  no  urine.  On  this  occasion  he 
took  19  drops  of  turpentine,  within  two  hours,  in  divided  doses.  Shortly 
after  taking  the  turpentine,  the  pain  in  the  left  kidney  suddenly  ceased, 
with  a  sensation  which,  to  use  the  patient's  own  words,  seemed  to  indi- 
cate that  "  something  had  suddenly  broken  in  the  kidney."     He  then 


TERMINATION.  571 

complained  of  pain  along  the  left  iliac  region,  which  continued  fur- 
several  hours,  and  ceased  as  suddenly  as  the  previous  })ain  had  fhnie. 
Alter  this,  all  attempts  to  void  urine  were  accompanied  with  pain  along 
the  urethra,  premonitory  to  the  expulsion  of  the  cysts  from  that  [)assage. 

He  continued  in  good  health,  with  the  exception  of  occasional  dull 
aching  pain  in  the  lumbar  region,  especially  the  left  side,  until  Decem- 
ber 9th.  He  then  i)assed  five  cysts,  but  all  smaller  than  the  previous 
ones;  and  no  more  were  passed  until  December  81st,  when  he  awoke  in 
the  morning  with  acute  pain  in  the  loins,  and  all  the  symptoms  pre- 
viously described  as  occurring  on  November  16th.  During  the  day  he 
passed  twenty  cysts — one  at  8  A.  M. ;  eleven  at  1  p.  m.  ;  five  at  7  v.  M. : 
and  three  at  11  p.  M.  The  cysts  passed  in  rapid  succession,  and  some 
were  of  a  size  as  large  as  a  small  walnut.  On  January  1,1855,  a  single 
cyst  was  passed  in  the  morning;  on  the  2d  two  others  ;  on  the  3d  cme; 
and  on  the  10th  two.  From  this  last  date  up  to  December  8th  (beyond 
which  the  history  is  not  carried),  he  continued  to  suffer  frequently  from 
attacks  of  pain  and  diflSculty  in  passing  urine,  followed  (»ften  by  the 
expulsion  of  cysts,  between  seventy  and  eighty  of  which  he  brought  to 
Dr.  Barker. 

Careful  examination  failed  to  detect  any  abdominal  enlargement. 

The  urine  often  contained  a  small  quantity  of  blood  during  and  after 
the  expulsion  of  the  cysts;  it  was  often  loaded  with  lithates  and  phos- 
phates; occasionally,  crystals  of  uric  acid  were  found  attached  to  the 
outer  surface  of  the  cysts.  The  general  health  suffered  little.  Alto- 
gether upwards  of  150  cysts  were  passed;  they  varied  in  size  from  a 
pin's  head  to  a  walnut.  The  larger  vesicles  contained  echinococci ;  but 
many  of  the  smaller  ones  did  not  contain  any. 

The  duration  of  the  symptoms  is  altogether  uncertain.  In 
some  of  the  cases  permanent  recovery  followed  one  or  a  few 
discharges  of  vesicles.  Other  patients  went  on  passing  hyda- 
tids for  three,  ten,  twenty,  and  even  thirty  years.  A  discharge 
of  vesicles  having  once  taken  place,  there  are  no  means  of  ascer- 
taining whether  any  more  will  follow.  Neither  the  number  of 
vesicles  voided,  nor  the  frequency  of  the  discharges,  supplies 
any  reliable  indication.  The  only  sign  of  value  is  the  lapse  of 
time  since  the  preceding  attack :  the  longer  the  interval  the  less 
probability  of  recurrence. 

The  usual  termination  is  recovery.  Out  of  sixt^'-three  cases, 
recovery  was  assumed  to  have  taken  place  in  twent}^;  in  most 
of  these  the  attacks  had  ceased  for  some  years.  In  sixteen 
cases,  vesicles  continued  to  be  discharged  at  the  date  of  the 
record;  in  nineteen  cases  the  termination,  was  fatal:  and  in 
eight  we  are  left  without  information.  Of  the  nineteen  fatal 
cases,  death  took  place  in  nine  from  causes  other  than  the  hyda- 
tid disease  (phthisis,  cancer,  gangraena  senilis,  etc.) :  so  that  only 
in  ten  (sixteen  per  cent.)  was  the  fatal  issue  attributable  to  the 
parasite.  Death  was  brought  about  in  these  ten  cases  in  diverse 
ways — by  bursting  of  the   cyst  into  the  bronchi,  by  pleurisy 


572  HYDATIDS    IN    THE    KIDNEY. 

from  pressure  of  the  tumor  on  the  thoracic  cavity,  suppuration 
of  the  sac,  etc.  In  a  case  reported  by  Dr.  Blackburn,  the  left 
kidney  was  the  seat  of  a  hydatid  cyst  which  had  burst  into  the 
pelvis  of  the  organ,  where  a  large  calculus  was  also  found;  the 
right  kidney  was  congenitally  absent :  so  that  the  abrogation  of 
the  function  of  the  left  (and  unique)  kidne}^  proved  necessarily 
fatal.i 

Etiology. — Hydatids  are  not  uncommon  in  England,  Erance, 
and  Germany :  more  rare  in  America  and  India.  There  is, 
however,  no  country  so  fearfully  infested  therewith  as  Iceland. 
According  to  Eschricht  (speaking  of  hydatids  in  any  part  of  the 
body),  a  sixth  part  of  the  population  are  afflicted  with  this 
parasite.  The  frequency  of  the  disease  is  due  to  the  vast 
number  of  dogs  in  that  country,  which  live  in  intimate  contact 
with  the  inhabitants,  and  are  greatly  infested  with  the  taenia 
echinococcus.  The  ova  of  the  parasite,  discharged  with  the 
excrements  of  the  dogs,  foul  the  dried  fish  which  forms  a  large 
part  of  the  food  of  the  population.  The  embryo  of  the  parasite 
thus  finds  its  way  into  the  stomach,  and  thence  travels  into 
different  parts  of  the  body,  giving  rise  to  hydatid  cysts. 

The  use  of  uncooked  meat  and  salad  is  evidently  an  easy 
source  of  infection,  in  places  where  dogs  are  numerous  and  live 
in  close  intercourse  with  their  masters.  Dr.  Barker's  patient 
had  been  for  a  year  a  vegetarian. 

Men  appear  more  subject  to  renal  hydatids  than  women — 
the  proportion,  in  our  sixty-three  cases,  was  forty-one  men  to 
twenty-two  women.  In  only  one  instance  was  more  than  one 
member  of  a  family  affected  :  in  that  case,  a  husband  and  wife 
passed  hydatids  by  the  urethra.^ 

The  mean  age,  in  forty-seven  cases,  was  thirty-four  years : 
the  youngest  was  only  four  years,  and  the  oldest  seventy-five. 

The  Diagnosis  presents  no  difficulty  when  a  tumor  exists  in 
the  side  and  hydatid  vesicles  are  voided  with  the  urine.  When 
the  vesicles  are  broken  in  the  passage,  the  laminated  structure 
of  the  pieces,  or  the  finding  of  echinococci-hooks,  decides  the 
nature  of  the  discharge. 

So  long  as  the  parent  cyst  remains  intact,  the  urine  preserves 
its  normal  characters,  and  the  diagnosis  turns  on  the  characters 
of  the  tumor  in  the  flank.  Hydatid  fremitus,  when  present 
(which  is  rare),  is  a  valuable  sign ;  but  its  absence,  as  we  have 
seen,  has  little  significance. 

Hydatid  tumor  of  the  kidney  is  most  liable  to  be  confounded 
with  hydronephrosis;  and  in  the  absence  of  discharge  of  vesi- 
cles, or  their  debris,  with  the  urine,  and  of  hydatid  fremitus,  the 

1  Lond.  Med.  Journ.,  1781,  p.  126. 

2  Gay,  Med.  Times  and  Gaz.,  1855,  T.  160. 


PROGNOSIS.  573 

diagnosis  is  extremely  difficult  or  impossible :  it  rests  chiefly  on 
the  indications  of  the  previous  histoiy. 

When  vesicles  are  voided  with  the  urine,  and  no  tumor  cun  be 
detected  in  the  flank,  the  seat  of  the  parent  cyst  is  sometimes 
indicated  quite  clearly,  to  be  the  kidney,  by  signs  of  nephritic 
colic — in  other  cases,  more  obscurely,  by  pains  in  the  back  and 
loins  or  about  the  crest  of  the  ilium.  When  these  indications 
fail,  a  careful  examination  of  the  pelvis  should  be  made  through 
the  rectum  or  vagina:  if  no  evidence  be  found  of  a  tumor 
between  these  parts  and  the  bladder,  it  may  be  inferred,  almost 
with  certainty,  that  the  parent  cyst  is  situated  in  the  kidney.' 

The  Prognosis  is  generally  favorable — much  more  so  than  in 
hydatid  cysts  of  other  internal  organs  (the  uterus  excepted),  on 
account  of  the  facility  and  safety  of  evacuation  b}'  the  urinary 
passages.  It  is  most  favorable  of  all  when  the  discharge  of 
hydatids  by  the  urethra  is  unassociated  with  tumor  in  the 
abdomen.  In  no  such  case  has  a  fatal  result  been  recorded : 
the  cyst  in  such  cases  may  be  inferred  to  be  small,  and  to  be 
situated  in  the  pyramidal  structure  of  the  kidney,  w^hence  its 
contents  find  easy  exit  through  the  infundibula. 

When  a  renal  tumor  exists,  the  issue  is  still  likely  to  prove 
favorable  if  the  cyst  has  opened  into  the  urinary  passages. 
There  is,  however,  some  risk  that  a  second  opening  ma}-  be 
formed  in  a  less  safe  direction  (into  the  lungs),  or  that  the  cyst, 
or  the  parts  around,  ma}^  suppurate.  This  latter  contingenc}'  is 
by  no  means  rare,  nor  is  it  necessarily  fatal.  In  several  instances 
large  quantities  of  pus  were  discharged  with  the  vesicles,  and 
yet  the  issue  was  favorable.  In  three  cases,  in  which  vesicles 
were  discharged  both  by  stool  and  with  the  urine,  the  termina- 
tion was  favorable.  In  an  instance  recorded  by  Fleckles,  a 
woman  who  had  had  a  tumor  in  the  side  for  many  years  voided 
frequently  hydatids  by  the  urethra,  and  subsequently  a  large 
quantity  by  vomiting.  At  the  date  of  the  report  the  case  was 
going  on  favorably.^  In  the  two  cases  in  which  the  cj'st  burst 
into  the  cavity  of  the  thorax,  the  termination  was  fatal. 

When  the  cyst  fails  to  open  a  passage  for  its  contents  into  the 
pelvis  of  the  kidney,  the  prospects  of  the  patient  are  much  more 
serious.     The  tumor  is  liable  to  attain  very  great  dimensions, 

1  Prof.  Otto  Spiegel  berg  (Arch,  fiir  Gyniikol.,  i.  1,  p.  146,  quoted  in  Schmidt's 
Jahrb.,  Bd.  146,  1870)  records  the  case  of  a  woman,  fet.  42,  who  for  lifteen  months 
had  had  a  tumor  in  the  right  hypogastrium.  It  was  movable,  distinctly  fluctuat- 
ing, and  about  the  size  of  a  man's  head ;  and  extended  downwards  towards  the 
brim  of  the  pelvis.  It  could  be  felt  and  moved  from  the  vagina,  and  was  fallen 
for  an  ovarian  cyst.  On  proceeding  to  perform  ovariotomy,  when  the  cyst  was 
opened,  two  echinococcus  membranes  escaped,  which  cleared  up  the  diagnosis.  A 
portion  of  the  kidney  was  left  behind.  The  patient  died  26  hours  after  the  opera- 
tion. 

2  Schmidt's  Jahrb.,  Bd.  87,  S.  205. 


57-1  HYDATIDS    IN    THE    KIDNEY. 

and,  by  its  pressure,  to  excite  inflammation  in  the  surrounding 
parts,  or  within  the  chest;  or  the  cyst  itself  may  suppurate  and 
be  transformed  into  a  vast  abscess.  The  operation  of  puncturing 
such  a  cyst  is  one  of  considerable  danger. 

Treatment. — The  indications  to  be  held  in  view  are,  to 
destroy  the  life  of  the  parasite,  to  facilitate  the  evacuation  of  the 
cyst,  and  to  combat  the  accessory  symptoms  and  complications. 

Whether  medicines  administered  internally  have  any  real 
power  to  destroy  the  life  of  a  hydatid  parasite,  or  to  facilitate 
the  evacMation  of  a  hydatid  cyst,  may  be  greatly  doubted. 
jSTevertheless,  oil  of  turpentine  has  obtained  a  certain  reputation 
on  the  strength  of  its  tseniafuge  properties.  The  echinococcus 
of  the  hydatid  vesicle  is  undoubtedly  identical  with  the  head  of 
a  certain  species  of  tapeworm;  but  the  condition  of  a  parasite 
free  in  the  intestinal  canal,  is  widely  difi'erent  from  the  encysted 
state  of  the  same  parasite  in  the  substance  of  the  kidney,  where 
remedies  can  only  reach  it  indirectly,  by  the  circuitous  route  of 
the  circulation.  Turpentine  was  given  in  a  large  proportion  of 
the  recorded  cases;  but  there  is  little  evidence  that  it  had  any 
beneficial  influence  beyond  its  diuretic  effects. 

The  escape  of  the  vesicles  in  Dr.  Babington's  case,  was 
thought  to  be  favored  by  a  course  of  iodide  of  potassium.^ 

A  variety  of  other  vermifuge  and  diuretic  medicines  have 
been  used,  with  more  or  less  show  of  success — calomel,  nitrate 
of  potash,  the  caustic  alkalies,  hemlock,  taraxacum,  etc.  Beraud 
states  of  his  patient,  that  whenever  he  took  white  wine,  and 
beverages  containing  nitre,  he  voided  a  much  larger  number  of 
vesicles  than  at  any  other  times.  On  two  different  occasions  he 
was  made  to  take  20  grains  of  nitre  in  dandeloin  tea,  and  each 
time  the  desired  effect  was  speedily  produced.^ 

Electro-puncture  has  also  been  practised  with  a  view  to  kill 
the  worm  ;  but  without  evidence  of  success. 

When  the  cyst  has  opened  into  the  pelvis  of  the  kidney,  the 
practitioner  is  able,  in  diverse  way,  to  facilitate  the  expulsion  of 
the  vesicles,  and  to  moderate  the  severity  of  the  accompanying 
symptoms.  Anodynes,  especially  opium,  the  warm  bath,  free 
use  of  diluents,  are  indicated  during  the  passage  of  the  vesicles; 
if  the  nephritic  paroxysm  be  intense,  blood  may  be  abstracted 
from  the  loins  by  cupping.  Sometimes  mechanical  aid  is 
required  to  assist  the  liberation  of  the  vesicles.  Dr.  Lettsom's 
patient  helped  their  transit  along  the  ureter  by  pressing  them 
forward  with  his  fingers;  and  in  several  cases  it  is  noted,  that 
patients  (mostly  women)  have  used  the  fingers  to  dislodge  vesi- 

1  In  two  cases  of  hydatids  of  the  liver,  I  have  seen  the  cyst  gradually  and  com- 
pletely contract  a^'ter  a  course  of  very  large  doses  (30  grains  t.  d.)  of  iodide  of 
potassium. 

2  Gaz.  d.  Hop.,  Aug.  11,  1832.     Beraud,  loc.  cit.,  p.  93. 


BILHAKZIA    H^MATOIilA  575 

cles  impacted  in  the  orifice  of  the  urethra.  The  use  of  tlie 
catheter  is  sometimes  required  to  relieve  the  retention  of  urine 
caused  by  vesicles  engaged  in  tlie  urethra  or  pressing  against 
the  neck  of  the  bladder. 

When  the  cyst  remains  closed,  measures  should  be  taken  to 
evacuate  its  contents.  In  similar  cysts  of  the  liver  I  have,  in 
four  cases,  adopted  the  following  plan  with  uniform  success,  I 
employ  a  tubular  gold  needle — like  tlie  needle  employed  in  sub- 
cutaneous injections,  except  that  it  is  about  twice  as  long.  The 
base  of  the  needle  is  mounted  on  apiece  of  India-rubber  tubing 
three  feet  in  length,  and  furnished  with  a  small  stopcock  at  its 
lower  end.  The  tube  is  first  filled  with  water  by  suction,  and 
the  stopcock  closed.  The  needle  is  then  thrust  into  the  most 
prominent  part  of  the  cyst,  and  the  lower  end  of  the  tube 
is  placed  in  a  vessel  on  the  floor.  When  the  stopcock  is  opened, 
the  fluid  begins  to  run — the  column  of  liquid  in  the  tube  acting 
after  the  manner  of  a  siphon,  and  exercising  a  soliciting  force 
on  the  contents  of  the  sac.^  The  wound  made  by  these  fine 
needles  is  so  minute  that  there  is  no  risk  of  extravasation  into 
the  peritoneum- — and  certainly  no  risk  of  peritonitis,  as  I  have 
tested  in  a  large  number  of  instances.  In  two  of  my  cases 
simple  puncture  by  the  needle  has  been  suflScient,  with  only 
a  withdrawal  of  a  drachm  or  two  of  the  contents,  to  destroy  the 
life  of  a  hydatid  parasite,  and  to  cause  it  to  pass  very  gradually 
into  obsolescence  and  absorption.^ 

It  must,  however,  be  remembered  that  evacuation  of  a  renal 
hydatid  is  not  so  urgently  called  for  as  the  evacuation  of  a  hydatid 
of  the  liver;  because  in  the  former  there  is  a  natural  tendency 
to  spontaneous  evacuation  by  the  urinary  channels,  with  very 
little  risk  to  life,  whereas,  a  hydatid  of  the  liver  has  no  such 
read}^  means  of  escape. 

II.— BILHAKZIA  H^MATOBIA.— Co6&o;(^. 

[Distoma  Hcematobiuni — Bilharz.) 

This  parasite  was  discovered  by  Bilharz,  while  conducting, 
with  Griesinger,  an  investigation  into  the  diseases  of  the 
Egyptians.  Bilharz  named  it  Distoma  Haematobium;  but  later 
writers  have  erected  it  into  a  separate  genus,  which  CobboLd  has 
named  Bilharzia  in  honor  of  the  discoverer.    It  is  an  elongated, 

^  This  plan  is  substantially  like  an  operation  with  the  more  recently  introduced 
aspirator,  but  the  force  used  is  of  more  gentle  and  safer  character, — see  a  paper  by 
the  author  "On  Exploration  and  Tapping"  in  the  Liverpool  and  Manchester 
Medical  and  Surgical  Keports  for  1873. 

^  For  a  case  of  hydatids  of  the  kidney  successfully  treated  by  aspiration,  see 
Brit.  Med.  Journ.,  1877,  ii.  p.  471.  "  ~  '  - 


576 


BILHARZIA    H^MATOBIA, 


Fig.  72. 


Bilharz ,      aighly 

magnified,     h  i  g,  the  male  ;   ab  c, 
the  female.     [After  Bilharz.] 


soft-skinned,  bisexual  entozoon,  three  or  four  lines  in  length,  of 
the  trematode  or  fluke  kind  (Fig.  72).     It  inhabits  the  branches 

of  the  portal  system,  and  the  minute 
veins  of  the  pelvis  of  the  kidney,  ureter, 
and  bladder.  So  common  is  it  among 
the  Egyptians,  that  Griesinger  found  it 
117  times  in  363  autopsies. 

The  male  (A  ig)  is  comparatively  thick 
and  short,  and  provided  with  a  gynse- 
cophoric  canal,  in  which  the  longer, 
filiform  female  [a  b  c)  is  lodged  during 
the  copulatory  act. 

The  Qgg  (Figs.  73  and  74)  are  oval 
bodies,  ^tq  of  ^^  inch  long,  with  a  spiny 
projection  from  the  anterior  end.  The 
embryo,  when  newly  escaped,  is  flask- 
shaped,  and  provided  with  cilia  (Fig.  74). 
This  creature  does  not  produce  much 
mischief  in  the  larger  veins ;  but  when 
lodged  in  the  smaller  vessels  of  the 
mucous  and  submucous  tissue  of  the 
urinary  and  intestinal  tracts,  it  engen- 
ders severe  and  often  fatal  disorganiza- 
tion. Griesinger  found  that,  in  the 
large  intestines,  it  gave  rise  to  a  disease  resembling  dysentery, 
and  that  it  was  a  frequent  complication  of  that  disease,  but  not 
the  essential  cause  of  it. 

The  ravages  of  the  Bilharzia  produce  much  more  serious 
results  in  the  urinary  channels  than  in  the  intestines.  It  chiefly 
aflects  the  bladder,  but  frequently  also  the  ureter  and  pelvis  of 
the  kidney. 

In  the  bladder,  it  gives  rise  to  injected  and  ecchymotic  raised 
patches,  varying  from  the  size  of  a  lentil  to  that  of  a  shilling, 
covered  with  a  tough  mucus,  or  with  grayish-yellow,  bloody 
exudation,  which  contains  masses  of  ova.  In  more  advanced 
stages  the  patches  are  more  elevated,  discolored,  mixed  with 
pigment  specks,  smooth  and  leathery,  or  soft,  friable,  and 
encrusted  with  gravelly  matter,  composed  of  uric  acid  and 
other  urinary  deposits,  mixed  with  ova  and  blood.  In  other 
cases,  the  patches  resemble  nodules  or  condylomata,  over  which 
the  mucous  membrane  is  sometimes  preserved  uninjured,  some- 
times thickened,  injected,  adherent,  or  detached. 

When  the  parasite  invades  the  ureter  and  pelvis  of  the  kidney, 
its  effects  are  still  more  destructive.  The  calibre  of  the  ureter 
is  narrowed  at  the  affected  spot.  Above  the  constriction,  the 
ureter  is  dilated  from  accumulation  of  urine;  the  pelvis  is  also 
distended,  and  a  hydronephrotic  condition  is  produced.     Or, 


MORBID    ANATOMY    AN1>    SYMP'J'OMS.  577 

inflaramation  and  suppuration  are  Hot  up,  and  Hovere  pyelitis 
ensues.  In  one  instance,  Griesini^er  found  the  kidney  distended 
into  an  enormous  sac  filled  with  })us — the  renal  tissue  being 
wholly  destroyed. 

In  addition  to  these  direct  results,  urinary  concretions  are  often 
foi-nicd  on  masses  of  ova,  and  grow  into  large  calculi.  This 
accounts  for  the  frequency  and  endemic  prevalence  of  calculous 
disorders  in  Egypt. 

Griesinger  remarks:  "These  various  changes  in  the  mechani- 
cal state  and  nutrition  of  the  uro-poietic  apparatus  fail  not  to 
react  most  deleteriously  on  the  entire  organism.  A  series  of 
cases  have  fallen  under  our  notice,  in  which  they  produced 
general  ill-health,  and,  at  length,  death.  Most  of  these  indi- 
viduals werefinall}'  cut  off,  v^ith  shattered  constitutions,  by  pneu- 
monia, dysentery,  and  the  like.  .  .  .  The  direct  signs  of  the 
disease  are  to  be  sought  in  the  uro-poietic  system,  but  especially 
in  the  urine.  Repeated  hsematuria  in  sickly  individuals,  from 
unknown  causes,  often  came  before  us  in  Egypt.  We  no  longer 
doubt  that  the  symptoms  were  produced  by  distoma-processes. 
The  eggs  of  the  distoma  were  found  by  Bilharz  in  the  urine  of 
a  boy  who,  during  convalescence  from  typhus,  suffered  from 
hsematuria.'  Symptoms  of  pyelitis,  or  slight  aflection  of  the 
bladder,  must  be  present  in  many  cases."  .  .  .  "Cases  also  came 
before  us  which  awoke  a  strong  suspicion  that  the  Distoma  dis- 
ease sometimes  runs  its  course  as  an  acute,  severe,  and  painful 
disorder.  We  found  on  two  occasions,  in  the  bodies  of  persons 
who  had  rapidly  died  from  an  unknown  acute  disease,  abundant 
recent  distoma-changes  in  the  bladder,  recent  pyelitis,  and  a 
uniform  dark-red  hypersemia  of  the  kidneys.  In  other  cases  of 
supposed  rapid  typhus,  the  same  changes  were  found  in  the 
bladder  and  ureter."  These  researches  open  a  wide  held  for 
conjecture.  Not  only  may  urinary  derangements  and  uraemia 
be  occasioned  by  the  ravages  of  the  parasite,  but  septic  infection 
may  arise  from  the  accumulation  of  heaps  of  dead  and  dying 
animals  in  the  portal  vessels;  or  the  animals  may  creep  into  the 
general  circulation,  and  iind  their  way  into  organs  of  vital  im- 
portance; in  one  instance  distoma  eggshells  w^ere  found  in  the 
blood  of  the  left  ventricle. 

In  a  note  to  his  remarkable  paper,  Griesinger  throws  out  the 
conjecture  that  the  endemic  hsematuria  of  hot  countries  may  be 
due  to  the  presence  of  this  worm  in  the  urinary  passages.  A 
most  interesting  confirmation  of  this  conjecture  has  been  sup- 
plied by  the  researches  of  Dr.  John  Harley.  Dr.  Harley  had 
an  opportunity  of  examining  the  urine  of  three  gentlemen  who 

1  Griesinger  states  that  the  clinical  aspect  of  the  subject  onl}-  began  to  engage 
their  attention  when  he  and  Bilharz  were  about  lo  quit  Egypt. 

37 


678 


BILHARZIA    H^MATOBIA. 


had  resided  at  the  Cape  of  Good  Hope,  and  who  had  been  sub- 
ject to  the  endemic  hsematuria  of  that  country.  One  of  them 
still  continued  to  be  affected  with  slight  hsematuria;  the  other 
two  considered  themselves  cured  of  the  hsematuria,  but  were 
subject  to  gravel.  In  the  deposit  from  the  u.rine  of  all  three, 
Dr.  Harley  detected  numerous  ova  of  the  Bilharzia.  The  con- 
dition of  the  urine  in  the  first  case  is  thus  described  by  Dr. 
Harley:  "Pale-amber  colored,  sp.  gr.  1017.6,  acid,  deposits  a 
deep  layer  of  dirtyish-white  flocculent  matter,  amongst  which 
were  two  short  opaque. filaments  about  the  -^j  of  an  inch  in 
diameter,  of  a  brownish  color  and  soft  consistence,  two  shorter 
and  wider  fragments  of  the  same  substance,  a  little  reddish  mass 
of  the  size  of  a  hemp-seed,  like  a  little  clot  of  blood,  and  nu- 
merous white  specks.  The  clear  limpid  urine,  when  acidulated 
with  nitric  acid  and  heated,  deposited  a  trace  of  albumen." 
Uric  acid,  oxalate  of  lime,  and  urates  were  also  sometimes  found. 
The  deposit,  examined  microscopically,  was  found  to  contain 
pus  corpuscles ;  and  the  filamentous  bodies  and  coagula  contained 
embedded  in  them  great  numbers — sometimes  thirty  or  forty,  or 
more — of  bright,  highly  refractive,  oval  bodies,  which  were  iden- 
tified as  the  ova  of  Bilharzia  (Fig.  73).     These  observations 

Fm.  73. 


Ova  of  Bilharzia  hjematobia,  found  in  the  urine  of  a  patient  suffering  from  the  endemic  hreniaturia  of 
the  Cape  of  Good  Hope,  a,  filament  of  mucus  containing  ova  embedded,  X  50;  b,  ova  as  they  appeared 
in  the  fresh  urine,  X  100-     [After  Harley.] 


seem  to  establish  the  parasitic  origin  of  the  endemic  hsematuria 
of  Cape  Colony,  and  render  it  extremely  probable  that  the 
endemic  hsematuria  of  Mauritius  and  other  hot  climates  has  a 
similar  origin. 

An  example  of  this  curious  disease  came  under  my  notice  in 
the  person  of  a  groom,  w^ho  had  been  in  the  employ  of  the 
Viceroy  of  Egypt.  I  am  indebted  to  m}^  friend  Dr.  Simpson 
for  an  opportunity  of  examining  the  case. 


MORBID    ANATOMY    AND    SYMl'TOMS. 


)79 


William  Ray,  set.  19,  was  admitted  into  the  Manchester  Infirmary 
under  Dr.  Simpson,  in  February,  1871.  He  stated  that  rather  more 
than  two  years  ago  he  went  to  Cairo,  as  groom  in  the  service  of  the 
Viceroy  of  Egypt.  After  a  stay  of  some  months,  he  went  to  Alexan- 
dria for  the  summer,  returning  to  Cairo  in  the  winter.  He  returned  to 
this  country  about  four  months  ago.  While  in  Egypt  he  had  been  in 
the  habit  of  drinking  the  water  of  the  Nile  unfiltered,  and  of  eating 
water-cresses  freely;  with  one  or  two  exceptions,  he  invariably  rode  his 
horse  bare-backed.  About  four  months  after  his  arrival  in  Cairo,  he 
observed  that  he  passed  bloody-looking  urine,  and  shortly  afterwards  he 


Bilharzia  in  urine.  I.  Free  embryos,  showing  the  different  shapes  they  assume  as  they  swim  about 
in  the  urine.  2.  Ova  containing  unhatched  embryos.  3.  Emptj'  shells  from  -which  the  embryos  have 
escaped. 

suffered  pain  in  the  back  and  perineum  when  riding.  Since  then  he 
has  persistently  passed  turbid  urine  containing  blood.  He  is  now  very 
ansemic  and  thin,  but  in  fair  health  apart  from  the  urinary  affection. 
On  the  10th  of  March  I  examined  the  patient's  urine.  The  specimen 
was  a  fair  sample  of  what  is  generally  passed.  It  was  smoky  and  turbid, 
with  an  abundant  reddish-white  deposit  in  which  might  be  seen  Jittle 
flakes  of  blood-clots;  it  was  neutral  to  test-paper,  specific  gravity  1010, 
and  contained  a  little  albumen — rather  more  than  the  blood  and  pus 
would  account  for.  Under  the  microscope,  the  deposit  was  seen  to  con- 
sist mainly  of  pus,  mixed,  however,  with  blood,  both  in  the  form  of 
shreddy  clots  and  as  free  corpuscles.  Both  ova  and  free  embryos  of 
the  Bilharzia  heematobia  were  present  in  considerable  numbers  (see 
Fig.  74).  The  embryos,  in  the  mature  ova  (2),  exhibited  slow  expand- 
ing and  contracting  as  well  as  oscillating  movements;  these  expansile 
movements  were  especially  seen  in  the  cervical  narrowing,  which  at  one 
time  became  very  marked,  and  anon  was  almost  effaced.  The  free 
embryos  (1)  moved  actively  in  the  urine  for  some  hours  after  its  emis- 
sion.    They  were  covered  all  over,  with  the  exception  of  the  head,  with 


580  BILHARZIA    HJEMATOBIA. 

long  vibrating  cilia,  by  means  of  which  they  moved  in  various  directions, 
with  intervals  of  quiescence.  At  times  an  embryo  could  be  seen  racing 
across  the  field  of  the  microscope  with  such  speed  that  the  eye  could 
scarcely  follow  it — at  other  times,  the  movement  consisted  in  stretching 
out  the  body  to  its  full  length,  and  then  retracting  it  to  an  oval  or  ball- 
shape.  When  moving  across  the  field,  the  body  turned  over  and  over 
on  its  longitudinal  axis.  Sometimes  the  head  was  retracted  into  the 
interior  of  the  body.  A  number  of  empty  eggshells,  with  irregular 
openings  in  them,  or  in  fragments,  were  also  seen  scattered  over  the 
field. 

This  patient  continued  under  observation  for  two  or  three 
weeks,  and  then  left  the  hospital  without  leave. 

In  this  case  all  the  ova  had  terminal  spines — not  lateral  ones 
— so  that  they  reserabled  exactly  the  ova  found  by  Harley  in  the 
cases  from  South  Africa.  Dr.  Harley  states  that  in  his  cases  he 
never  "  met  with  a  free  living  embryo  in  the  urine.  Eggs,  which 
split  open  and  liberate  active  embryos  immediately  after  they 
are  placed  in  water,  remain  quiescent  for  an  indefinite  time 
when  left  in  the  urine,  and  all  attempts  to  hatch  them  in  this 
fluid  kept  fresh  and  warm  had  invariably  failed"  ("  Med.-Chir. 
Trans.,"  vol.  54).  In  the  case  just  recorded  this  was  certainly 
not  the  case — the  embryos  moved  actively  in  the  urine  for 
several  hours  after  its  emission. 

It  does  not  appear  that  a  man  aft'ected  with  this  disease  is 
capable  of  transmitting  it  to  his  wife.  The  wife  of  one  of  Dr. 
Harley's  patients  had  three  or  four  healthy  children,  and  the 
husband  had  been  passing  numbers  of  the  eggs  of  the  parasite 
every  day  of  their  married  life — yet  the  lady  had  never  had  the 
slightest  symptoms  of  the  parasitic  disease,  and  the  urine  was 
free  from  all  traces  of  the  parasite.  It  seems  probable  that  the 
parasite  usually  gains  entrance  into  the  body  through  the 
stomach  by  means  of  drinking  infected  water  or  eating  salad,  to 
which  the  minute  animal  or  its  embryos  or  ova  adhere.  Dr. 
Harley  suggests  that  it  sometimes  obtains  admission  through 
the  skin,  that  the  minute  leech-like  animal  Axes  itself  to  the  skin 
of  a  person  in  bathing  or  wading,  and  implants  the  ova  in  some 
superficial  vein.  If  such  be  the  case,  it  is  easy  to  understand 
that  the  hatching  process  and  irritation  attending  the  movements 
of  free  embryos  would  result  in  an  indolent  form  of  ulceration, 
and  that  the  little  animals  might  be  carried  by  the  circulation 
from  the  legs  to  the  urinary  organs.  It  is  certain  that  new 
colonists  in  the  Cape  are  very  apt  to  be  attacked  by  indolent 
sores  on  the  legs,  and  it  seems  not  unlikely  that  their  origin 
may  thus  be  accounted  for. 

Of  the  treatment  of  this  parasite,  Dr.  Harley  observes :  "  I  have 
found  that  a  draught  composed  of  ti\^xv  each  of  oil  of  turpen- 
tine and  male  fern,  and  in^v  of  chloroform,  in  §ij  of  tragacanth 


FILARIA    SANaUINIS    HOMINIS.  581 

mixture,  given  every  morning,  brought  away  great  iiumherH  of 
tlie  ova.  The  sahne  condition  of  the  urine  in  much  diminished, 
and  the  renal  irritation  and  pain  due  to  the  presence  of  crystal- 
line  concretions  are  much  relieved  by  the  administration  of  bi- 
carbonate of  potash  in  copious  draughts  of  water.  The  alkali 
dissolves  the  uric  acid,  which  I  believe  to  be  the  cementing 
medium  of  the  oxalic  deposits,  and  thus  the  disintegration  of 
the  calculi  is  facilitated,  and  their  formation  prevented." 

From  the  researches  of  Siebold  on  the  trematode  worms,  it 
may  be  assumed,  that  between  the  ciliated  embryo  above  men- 
tioned and  the  adult  sexual  worm,  there  are  two  other  distinct 
forms,  which  serve  to  complete  the  chain  of  metamor[)hoses 
connecting  these  two  extremes  of  development.  Fresh  water 
mollusca  and  fish  are  probably  the  victims  selected  by  the  para- 
site during  its  development  through  these  intermediate  stages. 
Harley  on  these  grounds  suggests  the  following  prophylactic 
measures  in  districts  affected  with  endemic  hsematuria:  1.  The 
water  should  be  conve^^ed  from  its  source  to  its  destination  in 
covered  channels,  so  that  the  ova  contained  in  the  urinary  and 
fecal  products  of  those  infested  with  the  parasite  may  be  pre- 
vented mixing  with  it.  2.  Drinking  water  should  be  filtered. 
3.  Salads  which  may  entangle  small  mollusca  containing  para- 
sites, and  uncooked  mollusks  and  fish  (as  smoked  fish),  should 
be  carefully  avoided. 

When  the  ravages  of  the  parasite  are  confined  to  the  bladder 
and  prostate  local  means  may  be  employed.  Dr.  Harley  tried 
the  effects  of  injections  of  wormwood,  quassia,  and  iodide  of 
potassium.  He  obtained  good  results  only  with  the  last.  He 
recommends  a  solution  of  20  or  30  grains  of  the  iodide  in  5 
ounces  of  tepid  water  to  be  injected  every  second  or  third  day. 

III.— FILAEIA  SANGUINIS  HOMINIS.— iyew;is 

In  1872  Dr.  T.  R.  Lewis  made  the  interesting  observation 
that,  in  India,  chylous  urine  always  contained  large  numbers  of 
a  minute  nematoid  worm,  to  which  he  gave  the  name  of  Filaria 
Sanguinis  Hominis.  Further  observation  led  him  to  the  discovery 
that  the  same  worm  was  present  in  the  blood  of  chj^uric  patients, 
and  in  such  numbers  that  a  single  drop  of  blood  extracted  from 
the  finger  almost  invariably  showed  the  presence  of  one  or  several 
filarise.  The  symptoms  found  coincident  with  this  worm  by  Dr. 
Lewis  were  past  or  present  chyluria,  and,  less  frequently,  persist- 
ent diarrhoea,  conjunctivitis,  deafness,  elephantiasis  of  the  scrotum 
or  legs.  In  one  case  filariiTe  were  found  abundant!}'  in  the  blood 
of  a  man  three  years  after  the  chyluria  had  ceased. 

The  Filaria  Sanguinis  Hominis  is  a  long  narrow  worm  about 
the  breadth  of  a  red  blood-disk  and  -i^-^  of  an  inch  in  length  {see 


582 


FILARIA    SANGUINIS    HOMINIS. 


Fig.  75).  When  examined  in  fresh  drawn  blood  it  exhibits  very 
active,  wriggling,  snake-like  movements.  It  consists  of  a  deli- 
cate hyaline  tubular  envelope  closed  at  both  ends.  "Within  this 
the  worm  "elongates  and  contracts.  Under  a  magnifying  power 
of  600  diameters  transverse  strise  can  be  detected  and  granular 
aggregations,  but  no  distinct  evidence  of  oral  and  anal  orilices,  nor 
of  any  other  structure.  Its  habitat  is  the  blood,  and,  owing  to 
its  minute  size,  it  is  capable  of  circulating  through  the  capilla- 
ries. Whether  it  is  capable,  like  the  trichina,  of  inducing  gen- 
eral febrile  disease  is  uncertain — though  one  of  Dr.  Lewis's  cases 

Fig.  75. 


Filaria  Sanguinis  Hominis — from  a  drop  of  blood  obtained  by  pricking  the  finger  of  a  European 
woman  suffering  from  chyluria.  A  few  blood-dislss  are  introduced  to  show  the  relative  size  of  the 
rilarise.    X  300.     [After  Lewis.] 


indicates  this  pretty  strongly.  It  local  effects  are  supposed  to 
depend  on  the  formation  of  aggregations  of  filarise  which  block 
up  the  capillaries,  and  cause  by  their  active  movements  irrita- 
tion and  rupture  of  the  blood  channels  and  lymphatics,  and  thus  ' 
lead  to  the  appearance  of  chyle  and  blood  in  the  urine,  to  discharges 
from  the  cutaneous  surfaces,  with  thickenings  and  inflammation 
of  the  skin  and  intestinal  mucous  membrane — giving  rise  to  hy- 
pertrophv  (elephantiasis)  of  the  integument,  diarrhoea,  and  so 
forth. 

Dr.  Bancroft,  of  Brisbane,  discovered  iilariae  in  the  blood  of 
persons  suffering  from  chylous  urine  in  Queensland,  Australia. 
He  kindly  sent  me  some  specimens  preserved  in  glycerine  and 
water  enclosed  in  hermetically  sealed  capillary  tubes.     I  had  no 


FILARIA    SANGHJINIS    IIOMINIS.  588 

difficnlty  in  identifying  these  with  the  filarise  described  by  Lewis. 
Dr.  Biiiicroft  infers  from  his  experience  that  the  disease  is  not 
coninuinicated  frona  person  to  person  in  tlie  same  family,  but 
thinks  that  it  may  be  communicated  by  drinking  contaminated 
water.  Dr.  Bancroft  found  it  much  easier  to  detect  the  filarise 
in  the  blood  than  in  the  urine. 

The  iilaripe  found  by  Dr.  Bancroft  were  also  submitted  for 
examination  to  Dr.  Cobbold,  who  identified  them  with  Lewis's 
filari.Te,  and  showed  that  they  were  only  the  embryo  form  of  a 
worm  of  which  the  adult  was  as  yet  wanting.  Dr.  Bancroft, 
in  1877,  after  renewed  searchings,  was  able  to  announce  the 
discovery  of  the  adult  worm,  which  was  styled  by  Dr.  Cobbold 
Filaria  Bancrofti.  The  specimens  first  examined  were  obtained 
from  a  lymphatic  abscess  of  the  arm  and  from  a  hydrocele  of  the 
spermatic  cord,  and  were  discovered  to  be  examples  of  the  female 
worm.  It  is  about  three  inches  in  length,  and  at  the  thickest 
part  about  -Jq-  of  an  inch  in  diameter.  A  complete  uterine 
system  terminates  in  a  vaginal  pouch,  opening  near  the  head, 
and  from  the  genital  opening  large  numbers  of  the  embryo 
filariee  are  discharged.  The  discovery  of  the  adult  worm  has 
since  been  confirmed  by  Lewis  and  Manson,  the  latter  of  whom 
saw  the  parasite  in  situ  in  a  dilated  lymphatic.  The  male  worm 
has  not  yet  been  discovered. 

The  blood  of  a  patient  who  is  the  host  of  the  parasite,  does 
not  contain  the  embryo  filarise  at  all  times  of  the  day,  but  a 
most  remarkable  periodicity  has  been  observed  in  their  appear- 
ance. In  ordinary  circumstances,  the  filarite  make  their  appear- 
ance in  the  blood  at  sunset,  increase  in  numbers  up  to  midnight, 
and  then  gradually  diminish,  to  disappear  entirely  at  about  nine 
or  ten  o'clock  in  the  forenoon.  Manson  showed  that  this  perio- 
dicity was  interfered  with  by  a  febrile  attack,  but  Mackenzie 
{see  page  353)  made  the  remarkable  observation  that  the  perio- 
dicity could  be  completely  reversed  by  causing  the  patient  to 
rest  in  the  daytime  and  to  be  active  and  take  his  meals  during 
the  night.  Under  such  conditions  the  rise  and  fall  in  the  num- 
bers of  the  filarise  were  again  observed,  but  at  similar  hours  of 
the  day  and  not  of  the  night.  The  fate  of  the  filari^e  in  the  body 
is  as  yet  doubtful.  In  Dr.  Mackenzie's  case  the  number  of 
filari?e  in  the  blood  was  estimated  at  from  thirtj^-six  to  forty 
millions,  at  the  period  of  the  greatest  number. 

It  is  now  apparent  that  a  piatient  may  for  a  long  period  be 
the  host  of  this  parasite  without  showing  any  morbid  symptoms. 
It  is  evident  then  that  some  additional  circumstances  must 
occur  to  cause  the  severe  symptoms  mentioned  above,  which  are 
probably  due  to  obstruction  of  the  lymphatic  channels.  Manson 
is  of  opinion  that  this  event  is  nothing  else  than  an  abortion  of 
the  parent  worm.     In  the  early  stages  of  its  development  the 


584  STRONGYLUS    GIGAS. 

tilar'uil  embryo  ]ies  curled  up  in  its  capsule,  but  as  it  nears  matu- 
rity, gradually  elongates  and  stretches  its  capsule  until  it  as- 
sumes the  thread-like  form  in  which  it  is  usually  observed.  In 
this  shape  it  is  able  to  pass  freely  through  the  various  lymphatic 
and  hfemic  capillaries.  If,  however,  the  embryo  be  discharged 
into  the  blood  stream  before  the  process  of  elongation  is  com- 
pleted, according  to  Manson  its  more  rounded  shape  renders  its 
passage  along  the  smaller  lymph  capillaries  impossible,  and  the 
lymph  stream  is  hence  obstructed. 

The  researches  of  Manson  have  also  revealed  the  interesting 
fact  that  the  female  of  a  certain  species  of  mosquito  acts  as  the 
intermediary  host  to  the  parasite.  The  embryo  iilarise  shows  a 
tendency  to  curl  round  any  fine  object  with  which  they  are 
brought  into  contact.  In  this  way,  it  is  believed,  they  curl 
round  the  proboscis  of  the  mosquito,  and  are  so  transferred  to 
the  stomach  of  the  insect.  This  is  rendered  probable  by  the 
fact  that  the  blood  found  in  the  stomach  of  the  mosquito  con- 
tains more  filarise  than  the  blood  of  the  host.  Most  of  the 
filarise  embryos  are  either  digested  or  passed  out  with  the  feces 
of  the  mosquito.  Some,  however,  develop  and  are  finally 
liberated  by  the  death  of  the  mosquito  and  disintegration  of  its 
body.  Their  future  transference  to  man  is  probably  by  means 
of  drinking  water. 

IV.— STRONGYLUS  GIGAS,.— Rudolphi. 
[Eustrongylus  Gigas — Diesing.) 

This  is  the  largest  of  the  nematoid  worms,  and  in  its  general 
conformation  resembles  a  gigantic  lumbricus.  The  male  meas- 
ures from  ten  inches  to  a  foot  in  length,  and  a  quarter  of  an 
inch  in  breadth,  while  the  female  has  sometimes  a  length  of 
more  than  a  j^ard.  It  is  distinguished  from  the  common  round 
worm  by  its  reddish  color  (which  is,  however,  apparently  due  to 
the  sanguineous  fluid  in  which  it  is  usually  bathed),  its  greater 
size,  and  the  existence  of  six  nodules  or  papillae  round  the 
mouth.     The  Ascaris  lumbricoides  has  only  three  oral  papillse. 

The  worm  is  almost  peculiar  to  the  kidney  and  urinary  pas- 
sages, and  is  very  rarely  found  elsewhere.  It  inhabits  weasels, 
the  North  American  mink,  and  has  been  found  in  the  dog,  wolf, 
horse,  ox,  and  some  other  animals;  according  to  Schneider 
certain  kinds  of  fish  are  the  intermediate  bearers.  It  is  of  ex- 
treme rarity  in  the  human  subject.  Of  the  seventeen  alleged 
cases  collected  by  Davaine,  he  only  classes  seven  as  even  prob- 
able instances.  There  are  none  of  recent  occurrence ;  and  it  is 
evident  that  most  of  the  alleged  cases  were  really  examples  of 
lumbrici,  which  had  penetrated  into  the  urinary  passages  from 
the  intestines. 


ERRATIC    WORMS.  ;j85 

A  very  fine  apecinioti  in  prcsei'ved  in  tlio  niuHcuni  of  the 
London  College  of  Surgeons,  wliich  I  have  had  an  oj»[)ortiniity 
of  examining.  It  is  an  undoubted  strongyluH,  more  than  a  foot 
long.  It  originally  belonged  to  Brookes's  museum,  and  is 
entered  in  Brookes's  catalogue  as  "  an  uncommonly  fine  speci- 
men of  an  enormous  worm  (strongylus  gigas)  found  in  the 
kidney  of  a  patient  of  the  late  Thomas  Sheldon,  I^^sq." 


Fio.  76. 


V— PENTASTOMA    BENTlCU'LATUM.—RHdo/j./u,. 

This  is  a  very  minute  encysted  parasite,  about  a  line  and  a  half 
long,  club-shaped,  with  a  double  pair  of  hooks,  and  devoid  of 
sexual  organs  {see  Fig.  76).  It  is  conjectured 
by  Davaine  to  be  the  larva  of  pentastoma 
tsenioides,  which  infests  the  frontal  sinuses  of 
dogs  and  horses.  ISTo  symptoms  are  known 
to  be  produced  by  it. 

The  only  known  instance  in  which  the 
parasite  was  found  in  the  urinary  organs  is 
the  following :  In  making  the  autopsy  of  a 
painter,  sixty-two  years  of  age,  who  died  of 
Bright's  disease,  Wagner  found  on  the  convex 
border  of  the  right  kidney  a  small,  whitish, 
slightly  raised  oval  patch  of  fibrous  appear- 
ance, about  one-seventh  of  an  inch  long.  It 
was  situated  under  the  capsule  of  the  kidney. 
This  little  body  was  hollow  in  the  interior  :  it 
contained  a  yellowish  mass,  which  on  exami- 
nation disclosed  the  presence  of  a  worm, 
which  was  recognized  as  the  pentastoma 
denticulatum  of  Rudolphi. 

This  worm  is  common  on  the  surface  of  the 
liver  in  goats,  oxen,  rabbits,  cats,  and  some 
other  animals.  It  has  also  recently  been 
found  on  the  surface  of  the  liver  in  man,  by 
Zenker  in  Dresden,  ITeschl  in  Vienna,  and 
by  Virchow,  Wagner,  and  Frerichs  in  other 
parts  of  Germany.  Cobbold  states  that  Dr. 
Murchison,  during  the  time  he  held  the  office  of  Pathologist  at 
the  Middlesex  Hospital,  diligently  searched  for  it  without 
success. 


Pentastoma  tlenticulatum, 
greatly  magnifled.  [After 
Zenker.] 


VI.— ERRATIC  "WORMS. 


Intestinal  worms  sometimes  penetrate  into  the  urinary  pas- 
sages, and  are  voided  with  the  urine.  In  women  thread  worms 
occasionally  creep  into  the  bladder  through  the  urethra;  and 
in  both  sexes   lumbrici,  and  joints  of  tapeworm,  have   been 


586  SPURIOUS    WORMS. 

known  to  creep  into  the  bladder  through  fistulous  communica- 
tions caused  by  abscesses,  passage  of  pins,  lithotomy,  etc. 

VII.— SPURIOUS  WOEMS. 

The  spiroptera  hominis  of  Rudolphi,  the  diplosoma  crenata  of 
Farre,  and  the  dactylius  aculeatus  of  Curling,  have  been  clearly 
proved  by  Schneider  and  Cobbold  to  be  examples  of  imposition 
— witting  or  unwitting  on  the  part  of  patients.  The  history 
of  the  so-called  diplosoma  crenata  of  Farre  furnishes  one  of  the 
most  remarkable  examples  ever  put  on  record  of  long-continued 
and  successful  deception  practised  on  scientific  inquirers.  The 
following  references  may  be  consulted  on  the  subject :  W.  Law- 
rence, "  Med.-Chir.  Trans.,"  vol.  ii.  385;  A.  Farre,  "  Beale's 
Archives  of  Medicine,"  vol.  i.  p.  290 ;  A.  Schneider,  "  Reichert 
and  Dubois's  Archiv,"  1862,  p.  275 ;  Cobbold,  "  Entozoa,"  pp. 
403,  409;  CurHng,  "Med.-Chir.  Trans.,"  vol.  xxii.  p.  274. 


CHAPTEE  XIY. 

ANOMALIES  OF  POSITION,  FORM,  AND  NUMBER  OF  THE 

KIDNEYS. 

The  kidnejs  are  subject,  like  other  organs,  to  certain  devia- 
tions from  their  natural  situation,  form,  and  number.  Most  of 
these  deviations  are  cono;enital  ;  others  are  acquired  later  in 
life  throus^h  accident  or  disease.  Some  of  them  are  appreciable 
during  life,  and  are  liable  to  be  confounded  with  wholly  dif- 
ferent pathological  states;  others  are  entirely  latent,  and  are, 
so  long  as  the  healthy  state  is  maintained,  nowise  detrimental 
to  the  subject  of  them,  but  bring  greatly  increased  risks,  under 
certain  contingencies  of  obstruction  to  the  course  of  the  urine. 

I.— ANOMALIES  OF  POSITION. 

The  kidneys  may  occupy  an  unnatural  situation,  and  remain 
permanently  y?2:?<i  in  that  situation;  or  the  misplaced  organs 
may  possess  a  certain  mobility. 

A.  Fixed  Malpositions  of  the  Kidneys. 

The  kidney  may  be  displaced  downwards,  upwards,  or  later- 
ally, by  the  pressure  of  a  tumor  growing  in  its  vicinity,  or  by 
an  enlarged  liver,  spleen,  pancreas,  or  suprarenal  body;  in 
these  cases  the  malposition  is  acquired.  But  the  malposition 
may  also  be  congenital.  Instead  of  lying  beside  the  vertebral 
column,  deep  in  the  lumbar  region,  the  organ  may  be  fixed  in 
front  of  the  vertebrae,  or  on  the  brim  of  the  pelvis  or  within 
that  cavity  ;  in  a  case  figured  by  Ruysch,  the  kidney  lay  cross- 
wise, with  its  hilus  turned  upwards,  the  ureter  descending 
behind  it. 

A  kidney  congenitally  misplaced  usually  deviates  more  or 
less  from  its  natural  configuration,  and  is  associated  with  mal- 
position of  some  p)ortion  of  the  large  intestine  and  peritoneum. 
The  renal  artery  and  ureter  also  necessarily  deviate  less  or  more 
from  their  natural  distribution.  The  corresponding  suprarenal 
capsule  does  not  (in  congenital  cases)  follow  the  kidney  into  its 
abnormal  situation,  but  invariably  occupies  its  usual  place  in 
the  lumbar  region. 

By  far  the  most  common,  and  also  the  most  practically  im- 
portant, of  the  fixed  misplacements  of  the  kidney,  are  those  in 


588 


FIXED    MALPOSITIONS    OF    THE    KIDNEYS. 


which  the  organ  lies  within  or  upon  the  brim  of  the  pelvis.  In 
these  cases  the  misplaced  organ  is  liable  to  be  felt  during  life, 
either  through  the  abdominal  wall  or  the  vagina,  and  to  be 
mistaken  for  some  other  object;  if  it  lie  within  the  pelvis  it 
may  embarrass  and  complicate  parturition. 

In  twenty- one  cases  of  congenital  malposition  of  the  kidney 
which  I  have  been  able  to  collect  and  compare,  the  abnormality 
was,  in  every  instance,  confined  to  one  kidney,  and  the  left 
kidney  was  much  more  commonly  affected  than  the  right  (left 
15,  right  6). 

The  most  frequent  of  these  deviations  was  to  find  the  kidney 
lying  obliquely  on  the  sacro-iliac  synchondrosis,  as  represented 
in  Fig.  77.     In  some  of  the  cases,  the  organ  was  fixed  beside 


Fig.  77. 


Left  kidney,  lying  on  the  left  sacro-iliac  synchondrosis. 

Dr.  Kenaud.) 


(From  a  drawing  in  the  possession  of 


the  uterus,  or  transversely  between  the  rectum  and  bladder,  or 
across  the  prominence  of  the  sacrum. 

Mr.  Canton  has  described  and  figured  a  curious  specimen, 
taken  from  a  man  who  died  (of  bronchitis)  at  the  age  of  twenty- 
seven.  There  were  no  renal  symptoms  during  life.  The  right 
kidne}'  was  in  all  respects  normal;  but  the  left  was  situated 
below,  and  between,  the  bifurcation  of  the  aorta,  as  shown 


FIXED    MALPOSITIONS    OF    THE    KIDNEYS. 


589 


in  Fig.  78.  Instead  of  presenting  the  ordinary  kidney-Bhape, 
the  gland  was  rudely  oval,  and,  on  some  parts  of  its  surface, 
lobulated.  The  pelvis  of  the  organ  was  directed  almost  imme- 
diately forward,  and  tlie  upper  portion  of  the  ureter  was  dilated, 
owing  to  the  impaction  in  it  of  an  oxalate  of  lime  calculus, 
weighing    2|  drachms.     The    left   renal   arteries   were  two  in 

Fig.  78. 


Mr.  Canton's  case  of  misplaced  and  lobulated  kidney.     (From  the  the  Transactions  of  the  Pathological 

Society,  vol.  xiii.  p.  147.) 

number,  and  sprang  from  the  forepart  of  the  aorta  at  a  short 
distance  above  its  division.  The  sigmoid  flexure  of  the  colon 
was  placed,  as  represented  in  the  engraving,  on  the  right  side  of 
the  kidney. 

It  rarely  happens,  that  malpositions  or  this  class  produce  any 
evidence  of  their  existence  during  life;  but  sometimes,  as  in 
the  two  following  cases,  the  misplaced  organ  forms  a  palpable 
tumor  in  the  abdomen,  which  is  liable  to  be  mistaken  for  some- 
thing of  a  more  serious  character;  or,  in  the  female,  it  may 
constitute  an  obstacle  to  parturition. 


590  FIXED    MALPOSITIONS    OF    THE    KIDNEYS. 

Case  1.  Left  kidney  malformed,  and  situated  over  the  left  sacro-iliac 
synchondrosis,  mist  tken  for  an  abdominal  tumor  (Durham,  "  Guy's  Hosp. 
Reports,"  1860,  p.  407). — Mr.  W.  S.,  previously  in  good  health,  suf- 
fered, at  the  age  of  forty-five,  from  a  severe  attack  of  fever.  During  his 
recovery,  he  noticed,  for  the  first  time,  a  tumor  deeply  seated  in  the 
hypogastric  region,  somewhat  on  the  left  of  the  middle  line.  This 
tumor  was  found  on  examination  to  be  oval  in  form,  somewhat  elastic 
to  the  touch,  and  fixed.  It  was  not  nodulated,  nor  did  it  present  any 
distinctive  elevations  or  depressions.  Manipulation  gave  rise  to  very 
disagreeable  sensations,  but  not  to  acute  pain.  Considerable  alarm  was 
felt  by  the  patient,  especially  as  some  members  of  his  family  had  died 
from  "tumor  in  the  abdomen."  In  the  course  of  a  short  time,  when' 
convalescence  from  the  fever  was  established,  a  second  opinion  was 
taken.  The  conclusion  arrived  at  was,  that  there  existed  in  the  lower 
part  of  the  abdomen  "a  tumor  of  doubtful  character."  Iodine  oint- 
ment was  applied,  and  iodide  of  potassium  taken  internally.  The  treat- 
ment was  continued  for  some  time,  but,  of  course,  did  not  produce  the 
slightest  effect  on  the  tumor.  Mr.  S.  never  thoroughly  recovered  his 
health  and  strength,  and  about  four  or  five  years  after  his  attack  of 
fever,  died  of  pulmonary  disease. 

Autopsy. — Upon  opening  the  abdomen,  it  was  at  once  seen  that  the 
supposed  tumor  was  nothing  more  than  the  left  kidney,  which  was  situ- 
ated over  the  sacro-iliac  synchondrosis,  and  extended  somewhat  on  to 
the  promontory  of  the  sacrum,  and  also,  by  its  lower  part,  into  the  true 
pelvis.  The  colon  formed  no  sigmoid  flexure  in  the  left  iliac  fossa,  but 
passed  across  the  middle  line ;  and  the  commencement  of  the  rectum 
was  on  the  right  side  of  the  sacrum.  The  suprarenal  capsule  was  in  its 
normal  position.  The  kidney  presented  two  depressions,  which  divided 
its  surface  somewhat  indistinctly  into  three  portions.  The  principal 
arterial  supply  was  derived  directly  from  the  aorta,  by  a  branch  coming 
ofi"  just  above  the  bifurcation ;  a  branch  of  the  common  iliac  artery  of 
the  opposite  side,  and  a  branch  of  the  internal  iliac  of  the  same  side,  also 
supplied  different  parts  of  the  organ.  There  was  one  principal  vein, 
which  passed  from  the  internal  and  posterior  part  of  the  kidney  into 
the  vena  cava  just  above  the  junction  of  the  common  iliac  veins.  The 
ureter  resulted  from  the  junction  of  four  branches;  of  these,  two  came 
from  the  upper  and  posterior  part,  while  the  two  principal  ones  came 
from  the  anterior  and  lower  part ;  these  branches  joined  one  another 
about  an  inch  from  their  several  points  of  exit  from  the  organ.  Thus 
this  kidney  presented  no  distinct  hilus,  nor,  consequently,  did  it  possess 
the  characteristic  kidney-shape.  The  right  kidney  was  in  its  natural 
position,  and  both  glands  were  quite  healthy. 

Case  2.  A  misplaced  left  kidney  offering  an  obstacle  to  parturition 
(Hohl,  cited  by  Rayer,  loc.  cit.,  torn.  iii.  p.  774). — The  subject  of  this 
observation  was  a  woman,  in  whom  the  left  kidney  was  situated  deeply 
on  the  inside  of  the  psoas  muscle.  In  two  labors,  through  which  this 
woman  had  passed,  a  tumor  was  formed  each  time  on  the  left  side  of  the 
pelvis,  which  excited  fixed  and  increasing  pain  with  each  contraction  of 
the  uterus;  the  passage  of  the  head  was  thereby  retarded,  but  both 
accouchements  were  happily  accomplished. 


PHYSICAL    SIGNS    AND    SYMPTOMS.  591 

The  Diagnosis  of  a  misplaced  kidney,  forming  a  pelvic  or 
abdominal  tumor,  reste  on  the  moderate  sipce  and  the  smooth 
elastic  feel  of  the  tumor,  together  with  the  existence  of  a  want 
of  fulness,  or  a  slight  hollowing,  of  the  corresponding  lumbar 
region — denoting  the  absence  of  the  kidney  from  its  usual 
place.  The  shape  of  the  tumor  when  reniform,  of  course 
greatly  assists  the  diagnosis;  but  in  a  large  majority  of  such 
malpositions,  the  peculiar  kidney-shape  is  not  preserved.^ 

B.  Movable  Kidneys. 

Vague  allusions  to  mobility  of  the  kidneys  are  found  in  the 
works  of  the  old  writers  (Mesue  and  Riolan),  but  to  Rayer 
belongs  the  credit  of  having  first  pointed  out  the  practical 
bearing  of  this  condition,  and  the  symptoms  and  signs  by  which 
it  may  be  recognized  during  life.  In  this  country  the  subject 
has  been  ably  illustrated  by  Dr.  Hare.  Mr.  Durham  has  brought 
together  and  collated  all  the  instances  (10  in  number)  which,  up 
to  that  time  (1860),  had  been  verified  by  post-mortem  examina- 
tions. Oppolzer  and  Henoch,  in  Germany,  have  contributed  a 
number  of  cases ;  Fritz  has  analyzed  all  the  cases  published 
prior  to  1859.  Since  that  date  comprehensive  essays  on  the 
subject  have  been  contributed  by  Becquet  and  Rollet,  and  still 
more  recently  by  Landau.  The  following  account  is  based  on 
an  analysis  of  70  cases,  partly  derived  from  the  sources  above 
indicated,  and  partly  contributed  by  myself. 

Physical  Signs  and  Symptoms. — The  kidneys,  in  their  normal 
state,  are  secured  in  their  position  by  a  thick  investment  of 
adipose  tissue,  and  a  reflection  of  the  peritoneum  which  passes 
over  their  anterior  surfaces;  but  under  certain  circumstances, 
one  or  both  kidneys  break  away  from  these  not  very  iirm 
attachments,  and  float  loose  amid  the  abdominal  viscera — no 
longer  bound  except  by  their  bloodvessels  and  excretory  ducts. 
The  degree  of  mobility  and  of  change  of  position  which  the 
kidney  acquires  in  these  cases  varies  greatly.  In  the  generality 
of  cases,  the  organ  descends,  when  the  patient  is  standing 
upright,  below  the  margin  of  the  ribs,  and  occupies  a  diagonal 
position,  extending  from  below  upwards  and  outwards,  midway 
between  the  costal  border  and  the  umbilicus.  In  this  situation 
it  forms  an  oblong  tumor,  having  the  shape  and  feel  of  the 
kidney.  It  can  be  pushed  in  various  directions — upwards,  or 
downwards,  or  laterally — over  a  space  of  several  square  inches. 
In  persons  with  flaccid  bellies,  the  gland  can  be  actually  grasped 
with  the  hand ;  and  a  sickening,  sinking  sensation  is  experienced 

^  For  three  additional  cases  of  fixed  malposition  of  the  kidney,  .see  Hausmann, 
Monatsdi.  f.  Geburtsk.,  xxxiii.  p.  401;  Gosselin,  L'Union  Med.,  1869,  115;  and 
Powell,  Lancet,  1882,  i.  p.  1033. 


592  MOVABLE    KIDNEYS. 

when  it  is  compressed  ;  otherwise  it  is  usually  painless.  When 
the  patient  lies  horizontally,  the  displaced  kidney  can  be  thrust 
back- again  by  the  hand,  into  its  natural  situation  in  the  lumbar 
region;  but  it  generally  resumes  its  unnatural  place  when  the 
pressure  is  withdrawn.  The  respiratory  movements  and  the 
posture  of  the  body  exercise  a  marked  influence  on  the  position 
of  a  movable  kidney.  Deep  inspiration  causes  it  to  descend, 
and  deep  expiration  to  ascend;  it  falls  over  to  the  linea  alba,  or 
in  the  opposite  direction,  as  the  body  is  inclined  to  this  or  that 
side.  In  the  slighter  cases,  half  or  three-quarters  of  the  length 
of  the  organ  is  palpable  through  the  soft  abdominal  walls,  along 
the  borders  of  the  false  ribs:  but  the  displacement  is  generally 
more  considerable  than  this ;  in  a  case  mentioned  by  Johnson 
the  kidney  had  drifted  below  the  umbilicus;  in  another,  related 
by  Day,  the  kidney  lay  in  the  iliac  fossa,  and  could  be  moved 
hither  and  thither  over  a  space  of  three  or  four  inches.  When 
the  patient  reclines,  the  displaced  organ  occupies  a  higher  posi- 
tion than  after  long  standing  or  walking.  Percussion  does  not 
yield  a  dull  sound  over  a  movable  kidney,  but  a  muffled  tympa- 
nitic note.  When  the  loins  are  examined,  a  flattening  or  slight 
hollowing  of  the  renal  region,  on  the  side  of  the  displacement, 
is  perceived;  and  the  percussion  note  is  tympanitic — showing 
that  the  absent  kidney  is  replaced  by  intestine.  When  the 
organ  is  thrust  back  by  the  hand  into  its  original  position, 
the  natural  bulging  in  the  loin  is  restored,  and  the  bowel  sound 
disappears. 

The  subjective  sj'mptoms  vary  a  good  deal.  In  some  cases  the 
sj-mptoms  are  so  slight  as  not  to  attract  the  patient's  attention, 
and  the  anomaly  is  only  detected  by  an  accidental  examination 
of  the  abdomen  in  the  course  of  some  other  complaint.  There 
is,  however,  usually  marked  suflfering  and  inconvenience.  The 
most  common  symptoms  are  a  dragging  pain  in  the  side  aggra- 
vated by  walking  or  standing.  Sometimes  the  patients  are 
conscious  of  the  existence  of  a  movable  tumor  in  the  abdomen, 
which  gives  them  serious  uneasiness,  and  produces  a  hypo- 
chondriacal and  depressed  state  of  mind.  In  one  instance  the 
movements  were  mistaken  for  those  of  a  child  in  the  womb. 
Sometimes  the  stomach  is  disturbed^ — more  frequently  the  bowels 
are  affected,  either  with  fitful  diarrhoea  or  with  constipation. 
Pains  of  a  neuralgic  character  are  generally  experienced  in  the 
neighborhood  of  the  displaced  organ,  and  radiate  thence  in 
various  directions — into  the  loins,  round  the  waist,  down  to  the 
lower  parts  of  the  belly,  and  along  the  thighs. 

^  Digestive  disturbances  have  been  attributed  to  the  traction  which  a  movable 
kidney  on  the  right  side  may  exert  on  the  second  portion  of  the  duodenum. 
Obstruction  to  the  intestine,  so  produced,  has  been  said  to  have  caused  dilatation  of 
the  stomach.  (MuUer-Warneck,  Berl.  klin.  Wochenschr.,  1879,  No.  30;  Stiller, 
Wien.  Med.  Wochenschr.,  1879,  Nos.  4  and  5.) 


ILLUSTRATIVE    CASE8.  593 

In  some  cases  severe  puroxysnis  re8eml)liiii(  biliary  or  ne- 
phritic colic  occur  from  time  to  time,  accompanie(]  with  sickness, 
vomiting,  shivering,  faintness,  and  signs  of  local  j)eritoniti8. 
During  these  attacks  the  kidney  becomes  considerably  swollen, 
and  forms  an  immovable  and  paitiful  tumor  in  the  abdomen. 
When  the  paroxysm  has  subsided — which  it  usually  does  after 
a  few  days  of  rest  in  bed  and  the  use  of  opiates  and  warm  ex- 
ternal applications — the  kidney  becomes  again  reduced  in  size 
and  resumes  its  mobility,  Sometimes,  however,  it  contracts 
inflammatory  adhesions  to  the  parts  around,  and  remains  yier- 
manently  fixed  in  its  new  position.  The  exact  cause  of  these 
paroxysms  is  somewhat  obscure.  They  sometimes  set  in  sud- 
denly, while  the  patient  is  in  bed,  without  appreciable  cause; 
more  often  they  follow  some  unusual  exercise,  or  an  indigestible 
meal,  or  they  occur  at  the  menstrual  periods.  In  some  cases, 
at  least,  it  is  probable,  as  Gilewski  has  pointed  out,  that  they 
depend  on  a  sort  of  strangulation  of  the  kidney  from  the  pres- 
sure of  the  displaced  organ  on  its  own  ureter,  and  a  consequent 
obstruction  to  the  flow  of  urine,  followed  by  acute  engorgement 
of  the  kidney  with  dilatation  of  the  pelvis  and  pyelitis.  Such 
an  explanation  would  account  for  the  fact  that  the  urine  some- 
times becomes  bloody  and  purulent  for  a  time  after  one  of  these 
attacks  (Rollet,  1.  c,  p.  20). 

The  secretion  of  urine  generally  goes  on  without  any  altera- 
tion; but,  occasionally,  micturition  is  unnaturally  frequent,  and 
accompanied  with  more  or  less  pain.  Among  other  complica- 
tions which  have  been  observed  in  cases  of  movable  kidney 
may  be  mentioned  epigastric  pulsation,  the  discharge  of  uric 
acid  gravel,  the  occurrence  of  hydronephrosis,  Bright's  disease, 
osdema  of  the  lower  limbs  from  compression  of  the  ascending 
cava  by  the  displaced  kidney,  and  obstinate  constipation  from 
similar  compression  of  the  colon. 

The  following  examples  furnish  typical  illustrations  of  the 
physical  signs  and  of  the  varying  symptoms  associated  with 
movable  kidneys. 

Case  1. — On  the  19th  of  February,  1867,  I  saw  at  the  Crurapsall 
Workhouse,  with  Dr.  Simpson,  a  woman  named  E.  Canning.  She  was 
31  years  of  age,  and  was  suffering  from  chronic  phthisis.  She  had  had 
two  children,  the  younger  being  two  years  old ;  had  never  had  any  blow 
or  fall,  and  menstruation  had  always  been  regular  and  painless.  About 
three  weeks  previously,  she  discovered  a  "  lump"  in  her  right  side  after 
an  attack  of  diarrhcea,  and  called  the  attention  of  Dr.  Clarke,  the  resi- 
dent medical  officer,  to  it.  She  had  never  been  very  stout,  but  was  now 
considerably  emaciated. 

The  right  kidney  was  very  movable ;  as  the  patient  lay  on  her  back, 
it  occupied  the  position  indicated  by  the  continuous  line  in  Fig.  79, 
where  a  smooth,  slippery,  globular  object  was  felt,  which  was  evidently 

38 


594 


MOVABLE    KIDNEYS, 


the  lower  end  of  the  right  kidney.  By  thrusting  the  thumb  into  the 
loin,  the  tumor  was  pushed  forward  and  came  within  complete  reach  of 
the  hand,  so  that  it  could  be  partially  grasped,  and  thrust  back  into  the 
loin,  or  moved  about  in  a  circle  represented  by  the  dotted  line.  It  was 
felt  to  be  oblong,  with  rounded  smooth  ends.  The  left  kidney  was  also 
slightly  movable;  it  did  not  come  forward  towards  the  umbilicus,  but 

Fig.  79. 


Diagram  showing  the  area  over  which  the  right  kidney  could  be  moved  in  tlie  case  of  E.  Canning. 

when  the  patient  sat  up,  its  lower  end  could  be  felt  in  the  flank,  an  inch 
below  its  natural  situation,  and  it  could  be  pushed  up  until  it  disap- 
peared beneath  the  ribs. 

The  patient  suffered  no  inconvenience  whatever  from  the  state  of  the 
kidneys ;  but  as  she  was  constantly  in  bed,  she  was  scarcely  in  a  con- 
dition to  suffer  any.  Two  months  after  I  first  saw  her  she  died,  and  the 
body  was  examined  by  myself,  with  Dr.  Simpson  and  Dr.  Clarke. 

The  case  was  one  of  ordinary  pulmonary  tuberculosis. 

The  kidneys  were  found  quite  healthy;  the  right  lay  loose  in  the 
right  hypochondrium,  projecting  an  inch  and  a  half  below  the  margin 
of  the  liver ;  its  vessels  and  excretory  duct  formed  its  sole  attachments. 
There  was  scarcely  any  fat  about  it;  but  the  general  emaciation  was  so 
great  that  this  did  not  appear  singular.  There  was  no  abnormal  dis- 
tribution of  the  peritoneum,  nor  of  the  bloodvessels.  The  left  kidney 
lay  almost  in  its  normal  position,  but  about  an  inch  lower.  The  artery 
and  vein  of  the  right  kidney  were  half  an  inch  longer  than  those  of 
the  left. 


ILLUSTRATIVE    CASES. 


595 


Case  2. — Mrs.  D.,  set.  36,  the  mother  of  several  children,  had  been 
occasionally  under  Dr.  Hare's  care  for  several  years.  She  had  suffered 
from  ana3raia  and  oligo-raenorrhfjea,  but  got  quite  well  of  these.  .She 
had  afterwards  an  attack  of  gastrodynia,  when  she  had  also  much 
languor  and  debility,  with  weight  and  sinking  sensation  at  the  epi- 
gastrium. 

In  the  spring  of  1852,  Dr.  Hare  attended  her  for  a  slight  bronchial 
attack  ;  when  she  got  better  of  that  she  complained  of  a  "  beating  sensa- 
tion" down  the  middle  of  the  abdomen,  and  also  of  having  at  the  upper 
part  of  it,  on  each  side  "some  swellings  which  on  pressure  slipped  up 

Fig.  80. 


Diagram  showing  the  varying  positions  of  the  kidneys  in  the  case  of  Mrs.  D.  A,  A.  Margins  of 
costal  cartilages.  B.  Kight  kidney ;  ordinai-y  position  when  patient  is  in  recumbent  position,  f  C. 
Ditto,  on  deep  inspiration.  D  D.  Ditto,  position  to  which  it  can  be  moved.  E,  F.  Left  kidney ;  changes 
in  position  of.     [After  Hare.] 

under  the  ribs."  She  had  had  a  sinking  sensation  at  the  epigastrium 
for  years,  but  it  was  only  about  twelve  months  that  she  had  felt,  on 
applying  her  hand  there,  a  tumor  in  one  (the  right?)  hypochondrium, 
and  about  four  weeks  another  on  the  other  side.  The  aortic  impulse 
had  been  troublesome  for  five  weeks  past. 

On  making  an  examination  of  the  abdomen  (which  was  rather  thin, 
and  of  short  antero-posterior  diameter,  while  the  parietes  were  also 
flaccid),  the  aortic  impulse  was  found  to  extend  from  the  upper  part  of 
the  epigastrium  to  more  than  an  inch  below  the  umbilicus,  and  it  was 
exceedingly  well  marked  and  strong.  The  left  kidney  was  situated 
lower  than  usual,  but  readily  glided  when  pressed  upon,  from  under  the 
fingers,  deep  into  the  hypochondriac  region,  while,  on  the  other  hand,  it 
might  be  pushed  some  distance  downwards ;  the  right  kidney  presented 
the  same  phenomena,  except  that  it  was  much  more  mobile,  and  could 
be  detruded  downwards  so  far,  that  the  whole  of  it  could  be  felt  some 


596  MOVABLE    KIDNEYS. 

distance  below  the  costal  cartilages,  and  its  form  well  made  out,  owing 
to  the  thinness  of  the  parietes  (see  Fig.  80). 

A  belladonna  plaster  was  applied  to  the  abdomen,  and  some  tinct. 
ferri  sesqui'chlor.  and  tinct.  calumbse  were  given.  The  patient  was  after- 
wards seen  several  times  by  Dr.  Hare,  and  again  very  recently ;  at  times 
she  had  been  free  from  all  renal  pain,  but  lately  she  had  again  felt  some- 
what weaker,  and  she  had  had  more,  both  of  the  abdominal  impulse  and  of 
the  dragging  sensation  in  the  loins,  though  the  pain  was  by  no  means  so 
much  there  as  it  was  a  few  years  ago.  On  examining  the  abdomen,  the 
mobility  of  the  kidneys  (especially  of  the  left  one)  appeared  to  be 
less  than  formerly,  though  that  of  the  right  one  was  still  very  notable 
(Hare,  "Med.  Times  and  Gaz.,"  1858,  i.  p.  86). 

Case  3. — On  July  22,  1869,  I  was  asked  to  see,  with  my  colleague, 
Dr.  Morgan,  Mrs.  P.,  a  married  lady,  aged  27.  She  was  a  spare,  anae- 
mic, but  active  person.  tShe  had  had  six  children  in  little  less  than 
seven  years.  Previous  to  her  marriage  she  was  plump  and  rosy.  For 
several  years  she  had  suffered  from  profuse  leucorrhcea ;  but  with  the 
exception  of  occasional  dyspepsia,  she  had  enjoyed  fair  health  until 
Christmas,  1867,  when  she  was  suddenly  seized  while  in  bed  with  a 
violent  attack  of  shivering,  accompanied  with  retching  and  sickness  and 
intense  pain  in  the  situation  of  the  gall-bladder.  This  attack  lasted  48 
hours,  and  gradually  subsided  under  the  influence  of  morphia  and  hot 
fomentations.  From  this  time  (Christmas,  1867)  until  the  date  of  my 
visit  (July,  1869)  Mrs.  P.  was  frequently  subject  to  a  repetition  of  similar 
attacks,  which  occurred  at  longer  or  shorter  intervals.  At  one  time, 
during  many  consecutive  months,  the  seizures  came  on  every  fortnight. 
Any  unusual  exercise  or  excitement  was  sufficient  to  provoke  them. 
About  a  month  before  my  seeing  the  patient,  she  went  to  Buxton  and 
took  the  baths.  While  there  she  was  seized  with  one  of  her  old  attacks, 
but  of  greater  severity  than  any  previous  ones.  This  attack  lasted  for 
upwards  of  a  week,  and  one  morning  the  patient  discovered  a  swelling 
or  tumor  in  the  abdomen,  to  which  she  directed  the  attention  of  Mr.  Ship- 
ton,  who  was  in  attendance  on  her.  The  swelling  felt  like  the  end  of  a 
large  cucumber,  and  extended  downwards  from  the  situation  of  the  gall- 
bladder to  within  two  inches  of  Poupart's  ligament.  It  was  painful  on 
pressure,  and  it  had  made  its  appearance  somewhat  suddenly — for  no 
tumor  of  the  sort  could  be  detected  when  the  abdomen  was  examined 
five  days  previously.  Mr.  Shipton  considered  it  to  be  the  displaced 
right  kidney.  When  the  patient  was  examined  by  me  the  tumor  was 
much  smaller,  and  painless.  It  projected  from  beneath  the  margin  of 
the  liver  to  the  extent  of  about  two  inches.  It  was  evidently  adherent 
to  the  surrounding  parts,  and  could  only  be  moved  within  a  limited 
area.  It  had  a  smooth  rounded  outline,  and  appeared  about  the  size 
and  shape  of  the  lower  end  of  the  kidney.  It  could  not  be  pushed 
back  into  the  flank.  The  site  of  the  right  kidney  felt  flattened  and 
empty  as  compared  to  that  of  the  left  kidney.  I  had  no  doubt  that  the 
tumor  was  the  displaced  right  kidney,  and  that  when  first  perceived  by 
Mr.  Shipton  it  was  much  swollen  and  congested.  It  appeared  probable 
that  during  the  attack  at  Buxton  the  organ  had  contracted  inflamma- 
tory adhesions  to  the  surrounding  parts,  and  was  now  permanently  fixed 


ILLUSTRATIVE    CAHEH.  597 

in  its  new  position.     The  [)atient  was  fitted  with  an  abdominal  bandage, 
and  was  directed  to  avoi<l  all  violent  exercise. 

From  a  communication  I  received  from  Dr.  Morgan  on  April  15, 
1872,  I  learn  that  Mrs.  T.  has  suffered  very  little  from  the  tumor  since 
the  (late  of  our  visit  in  18G!).  She  wore  the  abdominal  belt  for  about 
two  years,  and  has  now  left  it  off.  The  only  time  she  suffers  much  dis- 
comfort in  the  region  of  her  erratic  kidney  is  at  the  menstrual  periods. 
For  some  two  days  before  the  catamenia  appear  the  kidney  seems  to 
become  larger,  is  sensitive  to  the  touch,  and  at  times  somewhat  painful 
even  without  being  touched.  Walking  exercise  does  not  suit  her,  and, 
if  prolonged,  is  apt  to  cause  discomfort  in  the  kidney;  but  she  can  ride 
on  horseback  or  dance  without  inconvenience.  The  kidney  still  occupies 
much  the  same  situation  as  in  1869. 

Case  4.— Mr.  D.,  set.  45,  consulted  me  in  July,  1870.  He  stated  that 
two  years  previously  he  had  fallen  on  the  ice  on  his  left  side,  and  that 
ever  since  he  had  suffered  from  d ragging-pains  in  the  right  loin  and  the 
neighborhood  of  the  ascending  colon,  with  irritable  bowels  and  loss  of 
flesh.  Although  moderate  exercise  caused  him  no  great  inconvenience, 
the  pains  always  disappeared  entirely  in  bed.  Two  or  three  loose 
motions  of  the  iDowels  occurred  daily.  Various  methods  of  treatment 
had  been  tried  without  any  relief. 

On  examining  the  abdomen,  I  found  an  oval  tumor  about  the  size 
and  shape  of  the  kidney,  lying  on  the  edge  of  the  pelvis,  in  the  vicinity 
of  the  caecum.  On  deep  pressure  it  slipped  upwards  from  under  the 
fingers;  very  little  pain  accompanied  this  manoeuvre.  When  the  loins 
were  examined,  a  conspicuous  flatness  was  perceptible  in  the  right  renal 
region.  There  was  no  doubt  that  the  right  kidney  had  descended  about 
its  own  length,  and  lay  in  the  iliac  fossa.  He  was  directed  to  push  up 
the  tumor  while  in  bed,  and  to  apply  a  tight  band  round  the  waist,  with 
a  pad  beneath  it,  over  the  position  of  the  displaced  organ. 

The  effect  of  the  treatment  was  immediate;  the  diarrhoea  entirely 
ceased,  and  the  dragging  pains  scarcely  troubled  him.  I  saw  this  gen- 
tleman several  times  subsequently ;  he  had  had  a  leathern  girdle  with  a 
pad  made  for  himself,  which  kept  the  kidney  approximately  in  its 
natural  position ;  and  so  long  as  he  wore  this  girdle  the  bowels  remained 
quiescent  and  the  pains  were  insignificant;  but  if  he  left  it  ofi",  the  old 
symptoms  returned  forthwith. 

I  am  indebted  to  the  late  Dr.  Ritchie  for  the  notes  of  the  two 
following  cases.  In  one  of  them  the  kidney  became  movable 
after  a  fall  on  the  loin;  the  other  illustrates  the  occurrence  of 
congestion  and  enlargement  of  the  kidney  at  the  menstrual 
periods. 

Case  5. — Mr.  J.,  set.  25,  came  under  my  care  on  24th  July,  1871. 
He  informed  me,  that  about  a  fortnight  previous  to  my  seeing  him,  he 
had  been  running  hurriedly  downstairs,  when  his  foot  slipped  off"  the 
edge  of  one  of  the  steps,  and  he  fell  backwards,  receiving  the  full  force 
of  the  blow  on  his  right  loin.  Between  the  accident  and  the  time  of 
my  seeing  him  he  had  been  in  constant  suffering,  and  by  the  advice  of 


598  MOVABLE    KIDNEYS. 

a  medical  man,  who  looked  on  the  case  as  one  of  "lumbago,"  had  assidu- 
ously employed  friction  with  various  liniments,  with  the  effect  of  aggra- 
vating and  not  alleviating  his  pain.  He  was  apparently  in  robust  health, 
with  the  ej?ception  of  the  ailment  for  which  he  sought  my  advice.  He 
complained  of  a  constant  dragging  sensation  in  the  belly,  which,  after 
standing  or  walking,  became  developed  into  a  severe  pain  darting 
between  the  right  loin  and  the  belly.  On  two  occasions,  after  prolonged 
standing,  he  had  also  pain  darting  down  the  right  thigh,  causing  him  so 
much  suffering  that  he  was  unable  to  attend  to  his  business.  On  examin- 
ing the  abdomen  a  hard  smooth  tumor  was  found  in  the  right  hypo- 
chondriac region.  It  was  quite  distinct  from  the  liver,  was  freely 
movable,  and  had  an  irregularly  rounded  outline.  Handling  the  tumor 
gave  rise  to  no  positive  pain,  but  to  sickening  sensations.  When  the 
patient  lay  on  his  back  the  tumor  could  not  be  discerned  unless  he  took 
a  deep  inspiration ;  it  then  appeared  to  pass  from  under  the  ribs,  re- 
ascending  with  deep  expiration.  It  could  be  most  readily  seen  as  the 
patient  lay  on  his  back  with  a  slight  inclination  to  the  left  side.  Per- 
cussion over  the  tumor  elicited  a  slight  amount  of  dulness.  There  was 
considerable  pulsation  in  the  abdominal  aorta,  extending  from  the  epi- 
gastrium to  about  an  inch  below  the'umbilicus.  The  patient  stated  that 
he  had  not  noticed  this  previous  to  his  accident,  and  that  it  became 
troublesome  if  his  bowels  were  constipated.  On  examining  the  lumbar 
regions,  the  right  was  seen  to  be  slightly  flattened  or  hollowed  out,  as 
compared  with  the  left ;  and  while,  on  percussing  the  left  lumbar  region, 
the  normal  renal  dulness  and  resistance  were  encountered,  the  right  was 
almost  perfectly  tympanitic.  There  were  no  urinary  symptoms.  A 
broad  flannel  bandage  was  firmly  fastened  round  the  patient's  abdomen, 
upon  which  he  expressed  his  relief  from  the  dragging  which  he  pre- 
viously complained  of.  This,  with  careful  regulation  of  the  bowels, 
appeared  to  be  all  the  treatment  indicated,  for  on  a  subsequent  visit,  a 
week  after  first  seeing  him,  he  stated  that  he  had  remained  perfectly 
free  from  pain  or  discomfort  since  the  application  of  the  bandage. 

Case  6. — M.  K.,  set.  17,  came  under  my  care  as  an  out-patient  of  the 
Hulme  Dispensary  on  8th  August,  1871.  She  was  thin  and  anaemic ; 
menstruation  regular  but  profuse.  She  stated  that  she  had  enjoyed 
moderately  good  health  till  about  six  weeks  prior  to  my  seeing  her, 
when  she  noticed  a  SAvelling  in  the  abdomen  on  the  right  side,  a  little 
below  the  ribs,  and  a  "great  fluttering"  at  the  pit  of  the  stomach.  Since 
then  the  bowels  had  been  very  irregular,  being  sometimes  constipated 
and  sometimes  very  loose.  The  fluttering  was  worst  when  the  bowels 
were  confined,  and  during  her  menstrual  period,  when  she  thought  the 
swelling  was  larger.  She  stated  that  she  had  never  been  in  the  habit  of 
tight  lacing,  and  no  account  of  any  fall,  blow,  or  extreme  exertion  could 
be  elicited  which  could  be  construed  into  a  probable  cause  of  the  swell- 
ing. On  examining  the  patient  in  the  erect  position,  a  smooth  hard 
swelling,  apparently  about  the  size  of  the  clenched  fist,  was  detected  just 
below  the  ribs  on  the  right  side.  Its  lower  margin  reached  to  within  an 
inch  and  a  half  of  the  anterior  superior  iliac  spine ;  it  was  movable  to 
a  greater  or  less  extent  in  every  direction  within  the  abdominal  cavity, 
but  the  greatest  mobility  was  in  the  direction  of  the  normal  site  of  the 


ETIOLOGY.  599 

kidney,  viz.,  upwards  and  backwards  beneath  the  ribs.  When  the 
patient  hiy  on  her  back,  the  hjwer  edge  of*  the  tumor  could  just  be  seen 
below  the  ribs  ;  it  could  be  seen  to  pass  much  lower  on  her  taking  a  deep 
inspiration.  The  tumor  was  sensitive  to  pressure,  and  the  examination 
gave  rise  to  nausea,  which  the  patient  afterwards  told  me  lasted  for  nearly 
two  hours.  There  was  no  great  difference  either  in  appearance  or  on 
percussion  between  the  right  and  left  luml)ar  regions.  There  was  strong 
pulsation  in  the  abdominal  aorta,  which  could  be  felt  through  the  thin 
parietes  to  be  slightly  on  the  right  of  the  median  line.  The  heart  and 
lungs  were  apparently  healthy;  there  were  no  urinary  symptoms  except 
a  slight  smarting  on  micturition,  which  came  on  synchronously  with  a 
vaginal  (gonorrheal?)  discharge  a  few  days  previously.  The  patient 
remained  under  observation  for  ten  weeks,  and  a  broad  flannel  bandage 
was  firmly  applied  to  the  abdomen.  After  the  cessation  of  the  discharge 
and  smarting,  she  was  put  on  cod-liver  oil  and  an  iron  tonic.  An 
opportunity  was  afforded  of  watching  the  tumor  during  two  menstrual 
periods — and  at  that  time  its  size  was  seen  to  be  increased  by  fully  one- 
half — it  was  much  more  sensitive  to  the  touch,  and  the  pulsation  of  the 
abdominal  aorta  was  considerably  stronger  than  during  the  intervals. 

Etiology. — Mobilitj  of  the  kidneys  is  much  more  common  in 
women  than  in  men;  and  more  common  on  the  right  side  than 
the  left.  Of  the  seventy  cases  which  I  have  collated,  sixty-one 
were  women  and  only  nine  men.  In  sixty-live  cases,  informa- 
tion is  given  as  to  the  side  affected  : 

In  42  the  right  kidney  alone  was  movable. 
In  9  the  left  kidney  alone  was  movable. 
In  14  both  kidneys  were  movable. 

The  age  of  the  patients  varied  from  sixteen  to  sixty-five  years 
— the  general  range  being  between  twenty -five  and  forty,  which 
corresponds  roughly  to  the  child-bearing  period  in  women. 

Mobility  of  the  kidneys,  judging  by  my  own  experience,  is 
much  more  frequent  than  is  usually  supposed ;  and  many  cases 
of  inexplicable  pain  in  the  abdomen  and  intestinal  disturbance 
are  due  to  this  cause.  A  large  number  of  cases  are  undoubtedly 
overlooked.  liollet  states  that  of  5500  patients  admitted  into 
Oppolzer's  Clinique,  and  examined  carefully  as  to  this  point,  22 
had  movable  kidneys — a  proportion  equal  to  1  in  250. 

In  a  certain  number  of  cases  no  clear  determining  cause  can 
be  discovered;  but,  as  a  rule,  the  antecedent  history  of  the 
patient  discloses  some  circumstance  or  circumstances  to'which 
the  anomaly  can  be  traced.  In  many  instances  the  affection  is 
due  to  repeated  or  difficult  labors ;  and  this  is  one  reason  of  the 
greater  frequency  of  movable  kidneys  in  women  than  in  men. 
The  alternate  tension  and  relaxation  of  the  abdomen  occurring 
in  successive  pregnancies,  and  the  convulsive  muscular  efforts 
which  accompany  parturition,  must  evidently  tend  to  loosen  the 


(500  MOVABLE    KIDNEYS. 

attachments  which  hold  the  kidney  in  its  place,  and  favor  its 
migration,  under  the  force  of  gravity,  into  a  lower  position  in 
the  abdomen. 

The  disproportionate  frequency  of  mobility  of  the  kidneys  in 
the  female  sex,  and  especially  on  the  right  side,  is  also  partly 
due  to  tight  lacing.  In  reference  to  this  point,  Cruveilhier 
observes:  "I  have  often  observed,  in  women  who  w^ore  tight 
stays,  the  right  kidney  to  lie  sometimes  in  the  right  iliac  fossa, 
sometimes  in  front  of  the  sacro-iliac  synchondrosis,  sometimes 
even  in  front  of  the  vertebral  column,  at  the  level  of  the  ad- 
herent border  of  the  mesentery,  in  the  substance  of  which  it 
was  placed.  The  kidney,  thus  accidentally  displaced,  enjoys  a 
certain  mobility.  This  displacement  of  the  kidney  arises,  when 
the  pressure  exercised  on  the  liver  by  the  stays  dislodges  the 
right  kidney  from  the  kind  of  niche  w^hich  it  occupies  on  the 
under  surface  of  this  organ. 

"  If  the  left  kidney  is  not  so  frequently  displaced  as  the  right, 
that  is  owing  to  the  fact  that  the  left  hypochondrium,  occupied 
by  the  spleen  and  the  great  end  of  the  stomach,  bears  the  pres- 
sure of  the  stays  with  much  more  impunity  than  the  right." 
(Cruveilhier,  "  Descriptive  Anat.,"  vol.  iii.) 

Eapid  emaciation  in  obese  persons,  and  the  removal  of  the 
capsule  of  adipose  tissue  which  naturally  invests  the  kidney, 
seem,  in  some  instances,  to  have  favored  or  determined  the 
mobility  of  the  organ.  Oppolzer  states,  that  in  the  cases  which 
he  had  an  opportunity  of  examining  —  the  patients  dying  of 
some  other  disease  —  there  had  always  been  observable  a  de- 
ficiency of  the  cushion  of  fat  about  the  kidney.  In  a  case  dis- 
sected by  Mr.  J.  Adams,  "the  only  peculiarity  remarkable  was, 
that  the  kidney  appeared  bound  down  in  its  situation  more 
loosely  than  usual,  and  the  old  lady,  from  having  been  very  fat, 
had  become  somewhat  thinner,  and  her  integuments  appeared 
very  lax  throughout."  ("  Med.  Times  and  Gazette,"  1857,  i. 
p.  651.) 

In  a  considerable  number  of  cases,  especially  in  men,  dis- 
placement and  mobility  of  the  kidney  is  produced  by  a  blow  on 
the  loin,  a  sudden  fall  or  jump,  violent  running,  dancing,  riding, 
or  severe  muscular  effort  or  succussion  of  the  body.  These 
causes  may  produce  their  effect  suddenly,  or  more  slowly  by 
frequent  repetition. 

Rayer  mentions  a  case  in  w^hich  it  appeared  probable,  that 
the  kidney  was  dragged  down,  or  at  least  left  free  to  descend 
from  its  own  weight,  in  consequence  of  displacement  of  the 
peritoneum,  from  a  hernia  of  the  caecum. 

Becquet  has  propounded  a  somewhat  novel  theory  for  the 
production  of  movable  kidneys  in  women.  In  the  cases  encoun- 
tered b}"  him,  there  was  a  striking  coincidence  of  time,  between 


ETIOLOGY.  001 

the  (lisplacemeut  oC  the  kidney  uiid  the  riieiintruul  [Xiriod  ;  and 
he  was  led  to  believe,  that  the  kidney  l)eeanie  congested  and 
tumefied  at  these  periodw,  and  that  displacement  was  the  con- 
sequence of  its  increased  volume  and  weight.  lie  thus  exf)lains 
himself:  "On  the  breaking  forth  of  the  menstrual  ilux,  the  kid- 
neys are  associated  in  the  congestion  of  the  generative  organs, 
and  become  swelled.  This  fact,  less  rare  doubtless  than  is 
usually  supposed,  perhaps  even  physiological,  does  it  not  ex|)lain 
the  renal  pain  so  often  felt  at  the  menstrual  periods,  especially 
in  women  who  are  subject  to  dysmenorrhagia? 

''  Thus  swelled  and  rendered  heavier,  the  kidney,  and  espe- 
cially the  right  kidney,  strains  the  feeble  attachments  which 
retain  it,  and  tends  to  start  out  of  its  yjlace.  Soon  the  con- 
gestion subsides,  and  the  organ  returns  to  its  original  position  ; 
a  second  congestion  displaces  it  further,  and  a  third  further 
still,  the  kidney  becoming  each  time  heavier  from  the  incom- 
pleteness of  the  resolution,  comes  to  occupy  a  lower  position; 
and  thus  gradually,  and  at  length,  but  not  without  sufiering, 
breaks  loose,  and  floats  in  the  abdominal  cavitv."  ("Arch. 
Gen.,"  1865,  i.  p.  21.) 

But  although,  in  a  majority  of  the  cases,  mobility  of  the 
kidney  appears  to  have  been  acquired  from  some  accident  or 
circumstance  arising  in  the  course  of  life,  there  are  instances  in 
which  a  congenital  anomaly  in  the  anatomical  connections  of 
the  gland  has  evidently  operated  to  favor  its  production. 

The  committee  appointed  by  the  Pathological  Society  to 
inquire  into  this  condition  recommends  that  two  varieties  be 
distinguished — movable  kidnej'S,  where  the  unnatural  mobility 
takes  place  entirely  behind  the  peritoneum,  awd  floating  kidneys, 
where  the  peritoneum  is  reflected  over  the  posterior,  as  well  as 
the  anterior  surface  of  the  kidney,  so  as  to  enclose  it  wnthin  a 
fold  of  peritoneum  or  meso-nephron,  which  permits  the  organ 
very  considerable  motion  in  the  abdomen.  The  two  conditions 
cannot  be  distinguished  during  life.  Mr.  Durham  examined 
the  body  of  a  woman  aged  34,  in  which  the  left  kidney  was 
very  movable.  He  found  the  descending  colon  much  nearer 
the  middle  line  than  usual,  and  instead  of  forming  the  sigmoid 
flexure  in  the  left  iliac  fossa,  it  turned  across  the  lumbar  verte- 
brae, and  passed  down  into  the  pelvis  on  the  right  side  of  the 
sacrum.  It  was  manifest  that  the  mobility  of  the  kidney  in 
this  instance  depended,  in  great  measure,  on  the  abnormal 
arrangement  of  the  peritoneum,  necessarily  associated  with  the 
malposition  of  the  colon.  So  far,  therefore,  it  must  be  regarded 
as  congenital.  When  traced  from  the  side  of  the  vertebral 
column,  the  peritoneum,  instead  of  passing  over  the  anterior 
surface  of  the  kidney,  only  just  touched  the  lower  part  of  its 
inner  border,  and   then,  having  formed  the  descending  meso- 


602  MOVABLE    KIDNEYS. 

colon,  again  touched  its  outer  border.  The  lesser  sac  of  the 
peritoneum  also,  instead  of  being  confined  to  its  ordinary  limits, 
passed  so  far  to  the  left  as  to  cover  the  posterior  surface  of  the 
spleen,  and  so  far  downwards  as  to  touch,  and  be  reflected  Irom 
the  upper  border  of  the  kidney.  Thus  there  was  no  distinct 
rneso-nephron,  but  the  kidney,  instead  of  being  supported  and 
kept  down  by  a  single  layer  of  peritoneum,  was  left  free  to 
move  between  and  beneath  three  diverging  layers.  Upon  dis- 
section it  was  further  found  that  there  was  scarcely  any  fat  in 
tho  lumbar  region,  but  a  quantity  of  very  loose  areolar  tissue. 
("Guy's  Hosp.  Rep.,"  1860.) 

The  Diagnosis  of  movable  kidney  is  chiefly  important,  from 
the  risk  of  confounding  an  ailment  which  is  comparatively 
trifling  with  some  graver  disease.  In  a  considerable  number 
of  instances,  the  affection  was  long  mistaken  by  the  patient  and 
his  medical  attendants  for  a  tumor  within  the  abdomen,  and 
the  patient  was  subjected,  in  addition  to  the  alarm  which  such 
a  notion  necessarily  engendered,  to  heroic  and  exhausting  or 
troublesome  plans  of  treatment.  The  diagnosis  is  indeed  gen- 
erally easy,  and  the  errors  committed  have  arisen  from  the 
possibility  of  this  condition  not  having  been  present  to  the 
mind  of  the  practitioner,  rather  than  from  the  inherent  ob- 
scurity of  the  case. 

A  movable  tumor  having  the  size  and  shape  of  the  kidney, 
or  approaching  thereto,  is  found  on  either  side  of  the  abdomen, 
generally  in  the  hypochondriac  region ;  it  can  be  pushed  into 
the  lumbar  space,  and  again  out  of  it,  at  will,  by  the  thumb 
and  fingers.  When  the  corresponding  loin  is  examined,  the 
absence  of  the  kidney  from  its  usual  .place  is  rendered  evident, 
by  the  flattening  or  hollowing  of  the  part,  and  by  the  tym- 
panitic note  yielded  on  percussion.  It  is  only  in  obese  indi- 
viduals, and  in  cases  where  the  displacement  and  mobility  are 
slight  that  any  difficulty  can  arise.  It  must  be  remembered 
that  the  displaced  organ  sometimes  contracts  adhesions  in  its 
new  position,  and  thereby  loses,  partly  or  wholly,  its  freedom  of 
movement. 

Treatment. — Persons  with  movable  kidneys  do  not  always 
suffer  serious  inconvenience  therefrom,  and  the  affection  may 
persist  without  much  change  for  an  indefinite  period.  But, 
as  a  rule,  unpleasant  or  painful  symptoms  are  produced,  which 
require  to  be  attended  to. 

The  most  evident  indication  is  to  replace  the  organ  in  its 
natural  position,  and  to  keep  it  there.  If  the  kidney  have 
contracted  adhesions  which  prevent  it  from  reassuming  its 
natural  site,  efforts  must  be  made  to  support  it  steadily  in  its 
new  place,  and  prevent  it  from  sinking  down  by  its  own  weight, 


TREATMENT.  603 

and  painfully  dragging  the  now  attachmentH  wliicli  it  Iiuh  formed.' 
These  ohjects  arc  attained  by  ap))lying  a  tight  bandage  or  belt 
round  the  abdomen.  This  hIiouUI  be  put  on  while  the  ])atient 
is  in  the  recumbent  position,  and  after  the  kidney  (if  this  be 
possible)  has  been  pushed  back  into  its  proper  place  in  the  loin. 
Sometimes  a  pad  fitting  on  to  the  place  where  the  organ  is  ac- 
customed to  protrude  gives  greater  effect  to  the  belt  or  bandage. 
Patients  cannot  always  bear  these  mechanical  appliances;  but 
in  many  cases  partial  or  coniplete  relief  is  afforded  by  them. 

Keppler^  considered  the  condition  so  dangerous  as  to  justify 
the  removal  of  the  organ.  His  opinion,  however,  has  not  heen 
supported  by  others.  Dr.  Newman  has  recommended  a  much 
less  dangerous  operation,  nephrorrhaphy,  in  which  the  kidney  is 
stitched  to  the  posterior  abdominal  wall.  The  operation  has 
been  performed  seven  times  abroad  and  once  by  Dr.  Newman, 
in  every  case  with  good  results.  Further  details  will  be  found 
in  Dr.  Newman's  thesis  (On  Malpositions  of  the  Kidney, 
"  Glasgow  Medical  Journal,"  Aug.  1883). 

If  there  be  anaemia  or  other  disorder  of  the  general  health, 
the  removal  of  this  by  appropriate  remedies  is  of  course  to  be 
attempted.  Restoration  of  the  tone  of  the  abdominal  muscles, 
which,  in  most  cases,  are  relaxed  and  flaccid,  is  probably  the 
most  effective  means  of  reducing  to  a  minimum  the  incon- 
veniences M'hieh  attend  on  mobility  of  the  kidneys.  To  this 
end,  ferruginous  and  other  tonics,  and  shower  baths,  with  avoid- 
ance of  fatiguing  exercise,  seem  to  be  the  means  best  adapted. 
A  curious  case  is  recorded  by  Dr.  Hare,  in  which  the  mobility 
of  the  kidneys  was  markedly  diminished  after  two  pregnancies: 
the  steady  pressure  of  the  gravid  uterus  having  apparently  acted 
as  a  mechanical  support  to  the  dislodged  organs. 

The  regulation  of  the  bowels  is  a  point  to  be  carefully  at- 
tended to.  Accumulation  of  fecal  matter  in  the  large  intestines 
invariably  aggravates  the  inconveniences  of  movable  kidneys. 
Tight  lacing  and  all  violent  modes  of  exercise  (equitation,  danc- 
ing) should  of  course  be  strictly  forbidden. 

When  the  symptoms  of  so-called  strangulntion  of  the  kidney 
occur — violent  pains,  sickness,  frequent  micturition,  enlargement 
and  excessive  tenderness  of  the  tumor — complete  repose,  in  the 
recumbent  posture,  should  be  prescribed  during  the  attack;  hot 
poultices,  or  even  leeches,  should  be  applied  over  the  seat  of 
pain,  and  morphia  administered  internally. 

1  In  cases  of  recently  formed  adhesions,  when  the  diagnosis  is  undoubted,  RoUet 
states  that  the  kidney  may  be  pushed  into  its  normal  position  by  force,  and  the 
aifection  be  at  once  and  permanently  cured.  This  seems  a  somewhat  hazardous 
proceeding. 

2  Archiv.  f.  klin   Chirurg.,  Bd.  2.3,  S.  520. 


604  ANOMALIES    OF    FORM 


II.— ANOMALIES  OF  POEM. 


Deviations  from  the  normal  shape  of  the  kidneys  may  exist 
congenitally, -or  be  produced  in  after-life  by  the  pressure  of 
tumors  or  of  enlargements  of  the  neighboring  organs.  Some 
of  these  malformations  have  been  already  noticed,  in  treating  of 
fixed  misplacements  of  the  kidney. 

The  lobulated  character  of  the  gland,  which  is  natural  to  it  in 
the  foetal  state,  sometimes  persists  more  or  less  throughout  life. 
Sometimes  one  kidney  is  twice  or  thrice  as  large  as  its  fellow, 
although  both  ma,j  be  perfectl}^  healthy — an  anomaly  probably 
due  to  deficient  development  of  one  renal  artery. 

The  pelvis  of  the  kidney,  and  the  ureter,  sometimes  present 
curious  anomalies.  Sir  H.  Thompson  encountered  a  kidney 
with  two  pelves,  which  united  into  a  single  ureter  about  an  inch 
below  their  necks  ("  Path.  Soc.  Trans.,"  vi.  267).  In  a  case 
recorded  by  Mr.  Wood  (Ibid.,  vii.  261),  the  left  kidney  had  two 
ureters,  which  continued  distinct  until  within  an  inch  of  the 
bladder.  The  right  kidney  of  the  same  patient  had,  in  addition 
to  a  ureter  which  entered  the  bladder  at  the  usual  place,  an 
aberrant  ureter,  connected  with  a  dilatation  (partial  hydrone- 
phrosis) at  the  upper  extremity  of  the  kidney;  this  aberrant 
duct  was  as  thick  as  a  goose-quill,  sacculated,  and  opened  into 
the  bladder  close  to  the  exit  of  the  urethra.  Dr.  C.  Kelly 
records  a  case  (Ibid.,  xix.  274)  in  which  no  trace  of  the  left 
kidney  could  be  found;  the  right  kidney  had  two  ureters — the 
upper  one  descended  in  the  usual  manner;  the  lower  one  passed 
behind  it,  and,  following  the  course  of  the  left  common  iliac 
artery,  entered  the  bladder  as  the  left  ureter  usually  does.  There 
were  three  arteries,  the  upper  of  which  was  in  the  usual  position 
of  the  right  renal  artery,  and  three  veins;  no  corresponding 
vessels  existed  on  the  left  side. 

Horseshoe  Kidney. — The  most  common  deviation  from  the 
normal  shape  of  the  kidney,  consists  in  the  fusion  of  the  two 
organs  into  one,  by  an  intermediate  transverse  portion,  or  isth- 
mus, which  connects  their  lower  ends  across  the  spine,  so  as  to 
form  a  crescent  or  horseshoe.  Fig.  81  represents  a  specimen 
which  I  removed,  some  years  ago,  from  the  body  of  a  patient 
who  died  of  phthisis  in  the  Royal  Infirmary.  The  two  halves 
of  a  horseshoe  kidney  are  usually  complete  and  perfect  in  them- 
selves, and  possess  each  a  separate  pelvis  and  ureter.  The 
transverse  portion  is  generally  composed  of  proper  secreting 
structure ;  but  sometimes  it  consists  merely  of  condensed  fibrous 
tissue.  The  concavity  of  the  crescent  is  nearly  always  directed 
upwards;  and  the  ureters  generally  descend  in  front  of  the 
transverse  portion — but  sometimes,  according  to  Wilks,  behind 
it.     In  a  drawing  possessed  by  my  colleague,  Dr.   Renaud,  the 


SOLITARY    KIJ)NPJY 


605 


two  ureters  of  a  horseshoe  kidney  are  seen  to  crosh'  euclj  other 
on  their  way  to  the  bladder.  The  arterial  supply  of  a  horse- 
shoe kidney  always  presents  some  departure  from  the  ordinary 
distribution. 

This  deformity  does  not  occasion  any  derangement  in  the 
secretion  of  urine,  i)rovided  the  organ  remain  healthy.  Kayei- 
reminds  practical  men,  that  in  thin  persons,  with  Haccid  bellies. 

Fig.  81. 


Horseshoe  kidney. 


the  transverse  portion  of  a  horseshoe  kidney  may  give  the  feel 
of  a  morbid  growth  in  the  abdomen ;  and  that  suppuration  and 
dilatation  of  the  pelvis  of  such  a  kidney  may  occasion  a  tumor, 
which,  from  its  central  position  near  the  spine,  would  lead  an 
observer  away  from  the  idea  of  a  pyonephrosis,  unless  the  possi- 
bility of  this  deformity  were  borne  in  mind.  Keufoille,  quoted 
by  Ebstein,  describes  a  case  in  which  congestion  of  a  horseshoe 
kidney  caused  pressure  on  the  inferior  vena  cava,  with  conse- 
quent thrombosis,  and  death. 


III.— ANOMALIES  OP  NUMBER. 

Rayer  cites  a  number  of  instances  in  which  there  existed  one 
or  two  supernumerary  kidneys,  each  with  its  separate  excretory 
duct.  The  same  author  cites  examples  of  stillborn  infants, 
presenting  a  complete  absence  of  both  kidneys,  together  with 
the  ureters  and  bladder.  In  acephalous  monsters  this  abnormity 
appears  to  be  not  uncommon. 

Solitary  Kidney. — The  absence  of  one  kidney  has  been 
repeatedly  observed  in  the  bodies  of  persons  who  presented  no 
derangement  of  the  urinary  function  during  life.  The  existing 
organ,  in  such  cases,  is  always  hypertrophied;  and  so  long  as 
it  remains  healthy,  the  secretion  of  urine  is  carried  on  without 
appreciable  defect.    But  if  the  solitary  kidney  become  inflamed, 


606  ANOMALIES    OF    NUMBER. 

or  its  excretory  duct  obstructed  by  the  impaction  of  a  calculus, 
or  the  pressure  of  a  tumor,  alarming  symptoms  make  their 
appearance,  accompanied  with  partial  or  total  suppression  of 
urine,  ending  in  fatal  urtemia.     See  Suppression  of  IJrine. 

Of  twenty-nine  cases  of  solitary  kidney  collected  by  me  from 
various  sources,  22  occurred  in  males,  6  in  females,  and  in  1 
case  the  sex  is  not  stated.  One  was  a  male  infant  seven  days 
old;  another  a  boy  of  seven  years  ;  two  of  the  cases  were  fifteen 
years  old ;  four  were  between  twenty  and  thirty,  three  between 
thirty  and  forty,  four  between  forty  and  fifty,  two  were  sixty, 
and  one  was  sixty-five — the  remainder  were  adults  whose  age  is 
not  specified.  The  left  kidney  was  absent  in  16  cases,  and  the 
right  in  12 — in  one  case  the  side  afiected  is  not  mentioned.  In 
nineteen  of  the  cases,  the  defect  was  congenital;  in  three,  it 
had  been  acquired  later  in  life  through  destruction  of  the  oppo- 
site organ ;  while  in  seven,  it  is  left  uncertain  whether  the 
defect  was  congenital  or  acquired.  The  renal  vessels  and  the 
ureter  of  the  defective  side  were  always  absent  in  the  congenital 
cases.  In  Dr.  Hillier's  ease,  the  existing  (right)  kidney  had 
three  arteries  and  two  ureters.  The  corresponding  suprarenal 
capsule  was  likewise  generally  wanting  when  the  defect  was 
congenital.^  In  24  cases  the  cause  of  death  was  specified:  in 
12  of  these,  death  was  essentially  conditioned  by  the  absence  of 
the  opposite  kidney — and  was  caused  in  10  cases  by  the  impac- 
tion of  a  calculus  in  the  ureter,  and  in  2  cases  by  the  pressure  of 
a  cancerous  growth  on  that  canal.  In  the  remainder,  the  cause 
of  death  was  unconnected  with  the  anomaly  in  the  kidneys.  In 
a  case  observed  by  ni}^  colleague.  Dr.  Leech,  solitary  kidney  was 
associated  with  double  uterus  and  vagina. 

In  addition  to  the  cases  collected  by  Rayer  and  Hosier,  the 
following  examples  of  solitary  kidney  may  be  referred  to : 
Garrod,  "Lancet,"  1863,  ii.  p.  724;  Rootes,  Ibid.,  1866,  ii.  p.  251; 
Ogle,  "Path.  Soc.  Trans.,"  1851-2,  p.  382;  Sydney  Jones,  Ibid., 
vol.  viii.  p.  279;  Murchison,  Ibid.,  vol.  x.  p.  190;  Hillier,  Ibid., 
vol.  XV.  p.  46;  Bruce,  Ibid.,  vol.  xvii.  p.  175;  Kelly,  Ibid.,  vol. 
xix.  p.  275;  Duckworth,  Ibid.,  vol.  xx.  p.  232;  Murrav,  "Brit. 
Med.  Journ.,"  1866,  ii.  p.  159;  Taylor,  Ibid.,  1870,"  ii.  485; 
Meschede,  "Virch.  Arch.,"  Bd.  33,  S.  546. 

1  Beumer,  however,  found  the  suprarenal  body  absent  in  only  5  out  of  48  cases. 
He  also  points  out  that  the  sexual  organs  are  frequently  arrested  in  development 
on  the  same  side  on  which  the  kidney  is  wanting. 


BIBLIOGRAPHY. 


PART  I. 

THE  PHYSICAL  AND  CHEMICAL  PEOPERTIES  OF  THE  UPvINE 
IN  HEALTH  AND  DISEASE— URINAKY  DEPOSITS. 

Prout — Stomach  and  Renal  Diseases.     5th  edit.,  Lond.,  1848. 

Willis — On  Urinary  Diseases.     Lond.,  1838. 

Beequerel — Semeiotique  des  Urines.     Paris,  1841. 

Bence  Jones — Animal  Chemistry.     Lond.,  1850. 

Bird — Urinary  Deposits.     5lh  edit.,  Lond.,  1857. 

Beale — Kidney  Diseases,  Urinary  Deposits,  etc.     3d  edit.,  Lond.,  1869. 

Parkes — Composition  of  the  Urine.     Lond.,  1860. 

Thudicum— Pathology  of  the  Urine.     Lond.,  1858;  2d  edit.,  1877. 

Neubauer  and  Vogel — Analyse  des  Harns.     Wiesbaden,  8th  ed.,  1881. 

Vogel  (J.) — Krankheiten  der  Harnbereitenden  Organe  (Virchow's  Handbnch  d. 

Path,  u.  Therap.,  Bd.  vi.).     Erl.,  1863. 
Hrtssall — The  Urine  in  Health  and  Disease.     2d  edit.,  Lond.,  1863. 
Rabuteau — Elements  d'Urologie.     Paris,  1875. 
Loebisch — Anleitung  zur  Ham-Analyse.     Vienna,  1881 
Salkowsky  and  Leube — Die  Lehre  voni  Harri.     Berlin,  1882. 

CHAPTER  IV. 

Paroxysmal  Hcemoglobinuria. 

Dessler — Virchow's  Arch.  f.  path.  an.  1854. 

Harley — Med.-Chir.  Trans.,  vol.  xlviii.  p.  161. 

Dickinson — Ibid.,  p.  175. 

Hassall— Lancet,  1865,  vol.  ii.  p.  369. 

Gull — Guy's  Hosp.  Reports,  3d  series,  vol.  xii.  p.  381. 

Greenhow— Clin.  Soc.  Trans.,   vol.   i.  p.   40;  and  Edin.  Med.   Journ.,  vol.  xiii. 

p.  996. 
Habershon — Lancet,  1870,  vol.  i.  p.  158. 
Wickham  Legs>; — St.  Bartholomew's  Hosp.  Rep.,  vol.  x. 
Druitt— Med.  Times  and  Gaz.,  1873,  vol.  i.  p.  408. 
Begbie— Edin.  Med.  Journ.,  May,  1875. 
Forest  and  Finlayson — Glasgow  Med.  Journ.,  1879. 
Saundby — Birmingham  Med.  Journ.,  vol.  xi. 
Mackenzie — Lancet,  1884. 

Lichtheini — Volkmann's  Samml.  klin.  Vortrage,  134. 
Ehrlich— Zeitsch.  f.  klin.  Medicin.,  iii.  p.  383. 
Boas— Deutsch.  Arehiv.  f.  klin.  Medicin.,  1883. 


608  BIBLIOGRAPHY. 


PART    II. 
CHAPTER  I. 

Diabetes  Insipidus. 

Willis — Urinary  Diseases,  p.  1.     Lond.,  1838. 

jTalck — Beitr.  z.  Lehre  von  d.  Einfache  Polyurie.     Deutsche  klin.,  1853. 

ISTeufter — ^Ueber  D.   Insip.   Tubingen  Thesis,   1856.      Canstatt's  Jaliresb.,   1857, 

iv.  234. 
Trousseau — Cliniqiie  Medicale,  1.  ii.  p.  611. 
Magnani — Du  Diabete  Insipide.     Strasburg  Thesis,  1862. 
P.  Eade — On  Diabetes  Insipidus.    Beale's  Archives,  vols.  ii.  and  iii. 
W.  Strange — Case  of  Diab.  Insip.     Beale's  Archives,  vol.  iii. 
Andersohn — Nichtzuckerfuhrender  Harnruhr.     Dorpat  Thesis,  1862. 
Merbach — Ein  Fall  von  Poljuirie.     Kiichenmeister's  Zeitsch.,  1865,  p.  10. 
Lancereaux — De  la  Polyurie.     Paris  Thesis,  1869. 
Strauss — Einfache  Zuckcrlose  Harnruhr.     Tubingen  Thesis,  1870. 
Dickinson — On  Diabetes.     Lond.,  1875. 
Kiilz— Diab.  Mell.  u.  Insip.     Marburg,  1875. 
Senator — Ziemssen's  Cyclopaedia,  vol.  xvi.,  1877. 
Lecorche — Traite  du  Diabete.     Paris,  1877. 

CHAPTER  II. 

DiABKTES    MeLLITUS. 

Prout — Stomach  and  Renal  Diseases,  chap.  ii. 

Bouchardat—AnnuairedeTherap.,  1841,  159;  1846,  Suppl.  162 ;  1848,227;  1849, 
136;  1855,  147;  1865,  291;  and  Clinique  Europ.,  1859,  217. 

Garrod — Gulstonian  Lects.  on  Diabetes.    Brit.  Med.  Journ.,  1857. 

Griesinger — Studien  liber  Diabetes.     Arch.  d.  Phys.  Heilk.,  1859. 

Ptivy — Diabetes:  its  Nature  and  Treatment.  Lond.,  2d  edit.,  1869;  Croonian 
Lectures.     London,  1878. 

p,-itz — Du  Diabete  dans  ses  rapports  avec  les  maladies  cerebales.  Gaz.  Hebd., 
1859,  264. 

Eischer — Diabete  consecutif  aux  trauraatismes.     Arch.  Gen.,  1862. 

Bernard — Legons  de  physiologic.  Paris,  1858  ;  Clinique  Europ.,  1859,  81 ;  Lon- 
don Medical  Record  for  1874. 

Erance — (Diabetic  cataract).     Guy's  Hosp.  Rep.,  3d  series,  vol.  vi.  226. 

V.  Graefe — (Diabetic  cataract).     Archiv.  f.  Ophthalm.,  1858. 

Lecorche — (Amblyopic  diabetique).  Gaz.  Hebd.,  Nov.  1861;  Traite  du  Diabete. 
Paris,  1877. 

Marchal  jde  Oalvi — Recherches  sur  les  Accidents  Diabetiques.     Paris,  1864. 

Roberts,  W.— On  the  Treatment  of  Diabetes.     Brit.  Med.  Journ.,  1860. 

Gray — (Treatment).     Glasgow  Med.  Journ.,  vol.  iv. 

SchifF  (J.  M.) — Untersuchungen  liber  die  Zuckerbildung  in  der  Leber.  Wiirz- 
burg,  1859. 


BIBLIOGRAPHY.  609 

Harley — On  Diabetes.     Lond.,  1800. 

Donkin — Skim-milk  Troutmcnt  of  Diabetes  and  Bright's  Disease.     Lond.,  1871. 

Kill/.— Beitrjlge  z.  Path.  u.  Therap.  d.  Diab.  Mell.     Marburg,  1874. 

Dickinson — On  Diabetes.     Lcmdon,  1875. 

Seegen— Diab.  Mcll.,  2d  ed.,  Berlin,  1875. 

Senator — Zierns.  Cyclop.,  vol.  xvi.,  Eng.  Trans,,  1877. 

Lauder  Brunton — Keynolds's  System  of  Med.,  vol.  v.     London,  187'J. 

Frerichs — Ueber  den  Diabetes.     Berlin,  1884. 

CHAPTER  III. 

Gravel  and  Calculus. 

Marcet — On  Calculous  Disorders.     Lond.,  1819. 

Prout — Nature  and  Treatment  of  Gravel  and  Calculus.     Lond.,  1821. 

Magendie — De  la  Gravelle.     Paris. 

Civiale — Traite  de  I'Atfection  Calculeuse.     Paris,  1838. 

Crosse — A  Treatise  on  Urinary  Calculus.     Lond.,  1841. 

Catalogue  of  Calculi  in  the  Museum  of  the  College  of  Surgeons.     Lond.,  1842. 

Kees — On  Calculous  Disease.     Lond.,  1850. 

Heller — Die  Harnconcretionen.     Vienna,  1860. 

Leroy  d'Etiolles  (Eils)— Traite  pratique  de  la  Gravelle.     Paris,  1863-4. 

Beale — Urine,  Urinary  Deposits,  and  Calculi.     3d  ed.     Lond.,  1809. 

Carter — Microscopic  Structure  and  Formation  of  Urinary  Calculi.     Lond.,  1873. 

Medical  Treatment  of  Oravel  and  Calculi. 

Chevallier — On  the  Dissolution  of  Gravel  and  Stone  in  the  Bladder.  (Trans- 
lated by  Edwin  Lee.)     Med.  Gaz.,  1837,  p.  430. 

Ch.  Petit — Du  Traitement  Medical  des  Calciils  Urinaires  par  les  Eaux  de  Vichy. 
Paris,  1834. 

Ch.  Petit — Nouvelles  Observations  de  Guerisons,  etc.     Paris,  1837. 

Ch.  Petit — Du  Mode  d'Action  des  Eaux  Minerales  de  Vichy.     Paris,  1850. 

Civiale — Du  Traitement  Medical  de  la  Pierre.     Paris,  1840. 

Thompson  (Sir  H.) — Preventive  Treatment  of  Calculous  Disease,  and  the  Use  of 
(Solvent  Remedies.     Lond.,  1873. 

CHAPTER  IV. 

Chylous  Urine. 

Prout — Stomach  and  Renal  Diseases,  5th  ed.,  p.  112. 
Rayer — Maladies  des  Reins,  torn.  iii.  p.  387. 
Bird — Urinary  Deposits,  5th  ed.,  p.  416. 

Bence-Jones — Phil.  Trans.  1850;  and  Med.-Chir.  Trans.,  vols,  xxxiii.  and  x'xxvi. 
Beale — Urine  and  Urinary  Deposits,  3d  ed.,  p.  299. 
Waters — Med.-Chir.  Trans.,  vol.  xlv.  p.  209. 
Carter— Ibid.,  vol.  xlv.  p.  189. 
Priestley— Edin.  Med.  Journ.,  1850,  p.  945. 
Bouchardat — Annuaire  de  Therapeutique,  1802,  p.  200. 
Pearse — Med.-Chir.  Trans.,  vol.  xxxiv.  p.  127. 
Ackermann — Deutsche  Klinik,  1808,  ISTos.  23  and  54. 

39 


610  BIBLIOGEAPHY. 

Isaacs — American  Journ.  of  Med.  Sci.,  April,  1860. 

Elliotson — Med.  Times  and  Gaz.,  Sept.  19,  1857. 

Dutt— Lancet,  1862,  vol.  ii.  p.  87. 

Begbie— Ed,.  Med.  Journ.,  Aug.  1862. 

Eggel — Inaug.  Diss.  Tubingen,  1869. 

Lewis — On  a  Hismatozoon  in  Human  Blood:  its  Relation  to  Chylaria  and  other 

Diseases — and   the   Pathological   Significance  of  ISTematode  Hsematozoa. 

Calcutta,  1874. 
Dickinson — Path.  Trans.,  vol.  xxix.  p.  891. 
Mackenzie — Path.  Trans.,  vol.  xxxiii.  p.  394. 
Sonsino — Med.  Times  and  Gaz.,  I.  1882. 
Manson — On  Filaria  Sanguinis  Hominis.     London,  1883. 


PART  III. 

CHAPTER  L 

Congestion  of  the  Kidneys. 

Robinson— Med.-Chir.  Trans.,  1843,  p.  51. 

Ererichs — Die  Bright'sche  Nierenkrankheit,  1851. 

Hermann — Sitzungsberichteder  mathem-naturw.   Classeder  Kais.  Akad.  Vienna, 

1861,  p.  26. 
Overbeck — Ueber  den  Eiweissharn,  Ibid.,  Eeb.  1868. 
Bouillaud — Archives  Generales.     4me  Serie,  torn.  xvii.  p.  99. 
Johnson — Diseases  of  the  Kidney.     Lond.,  1852. 
Virchow — Archiv  f.  path.  Anat.,  Band  iv. 
Traube — Ueber  den  Zusammenhang  von  Herz-  und  Nieren-Krankheiten.    Berlin, 

1856. 
Bamberger — Archiv  f.  path,  Anat.,  Bd.  xi.  S.  16. 

Rosenstein — Path.  u.  Therap.  d.  Nieren-Krankheiten.     2d  ed.     Berlin,  1870. 
J.  Vogel — Krankh.  d.  Harnbereit.  Org.,  Erlangen,  1865. 
Weissgerber  and  Perls — Arch.  f.  exper.  Pathologie,  1876,  vi.  p.  118. 
Posner — Virch.  Archiv,  vol.  79,  p.  311. 
Cornil  and  Brault — Pathologie  du  Rein.     Paris,  1884. 

Appendix. 

Lever — Guy's  Hospital  Reports,  1848,  p.  495. 

Devilliers  and  Regnauld — Archives  Generales,  1848. 

Frerichs,  1.  c,  p.  211. 

Wieger — Schmidt's  Jahrbiicher,  Band  87,  S.  57. 

Braun — On  Ursemic  Convulsions  in  Pregnancy  and  Parturition.     Translated  by 

Dr.  Matthews  Duncan.     Edin.,  1857. 
Rosenstein,  1.  c,  p.  62. 

Abeille — Traite  des  Maladies  a  urines  albumineuses  et  sucres.     Paris,  1863. 
Braxton  Hicks — Trans,  of  Obst.  Soc,  viii.  823. 


BIBLIOGRAPHY.  611 

Barnes — Ibid. 

Schroder — Lehrbuch  d.  Gebtirtsch.,  5lh  ed.,  1877. 

Leyden — Zeitsch.  f.  klin.  Mcdicin.,  Bd.  II.  S.  171. 

Hiiler— Ibid.,  Bd.  II.  S.  085. 

Bartels — Ziemssen's  Cyclofjsod.,  Eng.  Trans.,  vol.  xv.  p.  304. 

Wagner — Ibid.,  Morbus  Brightii,  3d  ed.,  p.  193. 

Flaischlen — Zeitsch.  f.  Geburtsch.,  vol.  vii. 

CHAPTER  II. 

Briqht's  Disease. 

Bright — Eeports  of  Medical  Cases,  vol.  i.     Lond.,  1827.     Also  papers  in  Guy's 

Hospital  Reports  for  1836  and  1840. 
Christison — On  Granular  Degeneration  of  the  Kidneys.     Edin.,  1839. 
Osborne — On  Dropsies  Connected  with  Suppressed  Perspiration  and  Coagulable 

Urine.     Lond.,  1835. 
Rayer — Traite  des  Maladies  des  Reins.     Paris,  1839,  1840. 
Johnson   (Geo.) — On   Diseases  of  the  Kidneys.     Lond.,  1852;   also  Med.-Chir. 

Trans.,  vol.  xlii.,  and  Ibid.  vol.  Ivi.  ;   and   Lectures  on  Bright's  Disease. 

Lond.,  1873. 
Simon — Med.-Chir.  Trans.,  vol.  xxx.  p.  153. 
Rees  (G.  0.) — On  the  Nature  and  Treatment  of  Diseases  of  the  Kidney.     Lond., 

1850. 
Prerichs — Die  Bright'sche  Nierenkrankheit.     Braunschweig,  1851. 
Todd — Clin.  Lects.  on  Certain  Dis.  of  Urin.  Organs.     Lond  ,  1857. 
Wilks — Guy's  Hosp.  Reports,  2d  series,  vol.  viii. 
Dickinson — Med.-Chir.  Trans.,  vols,  xliii.  and  xliv.,  and  on  the  Pathology  and 

Treatment  of  Albuminuria.     Lond.,  1868. 
Friedreich  and  Kekule — Arch.  f.  Path.'Anat.,  Bd.  xvi.  S.  50. 
Beckmann — Ibid.,  Band  xiii.  S.  94. 
Wagner — Archiv  der  Heilkunde,  1861,  p.  481. 

Rosenstein — Path.  u.  Therap.  d.  Nierenkrankheiten.  2d  ed.  Berlin,  1870. 
Grainger  Stewart — Bright's  Diseases  of  the  Kidneys.  2d  ed.  Edin.,  1871. 
Traube — Ueber  den  Zusammenhang  von  Herz-  und  Nierenkrankheiten.     Berlin, 

1856;  also  Deutsche  Klinik,  1859,  p.  6;  und  Schmidt's  Jahrbucher,  1862, 

No.  3. 
C.  Schmidt — Ann.  de  Chem.  u.  Pharm.,  Band  Ix.  S.  250. 
Richardson  (B.  W.) — On  Ursemic  Coma.     Clinical  Essays.     Lond.,  1862. 
Petroff — Zur  Lehre  von  der  Uramie.     Archiv  f.  Path.  An.,  Bd.  xxiv.  S.  91. 
Treitz — Ueber  Urjim.  Darmaftectionen.  Prag.  Vierteljahrschrift,  1859. 
Hammond  (W.  A.) — On  Un'emic  Intoxication.     Amer.  Journ.  of  Med.  Sc,  1861, 
Goodfellow — Diseases  of  the  Kidney  and  Dropsy.     Lond.,  1861. 
Schottin—Arch.  d.  Heilk.,  1860,  p.  417. 
Bernard  and  Barreswil — Archives  Gener.,  1847,  p.  449. 
Virchow — Archiv  f.  path.  Anat.,  Bd.  vi.  and  viii. 
Oppler — Beitr.  z.  Lehre  v.  d.  Arch.  f.  path.  Anat.,  Bd.  xxi.  S.  260. 
Zalesky — Untersuch.  u.  d.  Uramischen  Process.     Tub.,  1865. 
Harley — On  Albuminuria.     Lond.,  1866. 


612  BIBLIOGRAPHY. 

Basham — On  Dropsy.     3d  ed.     Lond.,  1866. 

Gull  and  Sutton— Med.-Chir.  Trans.,  vol.  Iv.  273. 

Galabin— On  the  Connection  of  Bright's  Disease  with  Changes  in  the  Vascular 

System.     Lond.,  1874. 
Mahomed — Etiology  and  Pre-albuminuric  Stage  of  Bright's  Disease.     Med.-Chir. 

Trans.,  vol.  Ivii.  197.     Lancet,  i.,  1879. 
Broadbent — Lancet,  1875,  ii.  p.  902. 
Klein — Keports  to  the  Privy  Council,  1876,  p.  39. 
Greenfield— Atlas  of  Pathology,  Syden.  Soc. 
Southey— Brit.  Med.  Joarn.,  I,  1881. 
Bartels — Ziemssen's  Cyclop.,  Eng.  Trans.,  vol.  xv. 
•Wagner — Ibid.,  Morbus  Brightii,  3d  edition. 
Thoma — Virch.  Archiv.,  vol.  Ixxi.  pp.  42  and  227. 
Ewald — Ibid.,  vol.  Ixxi.  p.  453. 
Senator — Virch.  Archiv,  vol.  Ixxiii.  pp.  1  and  313. 
Leyden — Zeitsch.  f.  klin.  Medicin,  vol.  ii.  p.  133. 

CHAPTER  V. 

Suppuration  in  the  Kidney  ;  Eenal  Embolism. 

Howship — A  Practical  Treatise  on  the  Complaints  Affecting  the  Secretion  and 

Excretion  of  the  Urine.     Lond.,  1833,  p.  21. 
Kayer — Malad.  des  Eeins,  tom.  ii.  and  iii. 
Johnson — Diseases  of  the  Kidneys.     Lond.,  1852. 
Todd— Clin.  Lect.  on  Urin.  Dis.     Lond.,  1852. 
Kirkes — Med.-Chir.  Trans.,  vol.  xxv. 
Virchow — Gesammelte  Abhandlungen,  p.  602. 

Traube— Ueber  den  Zusammenhang  von  Herz-  und  Nierankrankheiten,  p.  77. 
Beckmann — Archiv  f.  path.  Anat.     Bd.  xli.  S.  59. 
Chambers — Decennium  Pathologicum— Kidneys.    Brit,  and  For.  Med.-Chir.  Kev, , 

vol.  xxxvi.  p.  489. 
Moxon— Thrombosis  of  Pvenal  Veins.     Path.  Soc.  Trans.,  1869,  p.  227,  and  1870, 

p.  248. 
F.  J.  Eoberts — Eenal  Abscess,  Eeynolds's  System  of  Medicine,  vol.  v.  p.  595. 
M.  Beck — Consecutive  Nephritis,  Ibid.,  p.  529. 
Ebstein — Ziemssen's  Cyclop.,  Eng.  Trans.,  vol.  xv.  p.  543. 

CHAPTER  VI. 

Pyelitis  and  Pyonephrosis. 
Eayer — Loc.  cit.,  t.  iii. 

Bright — Memoirs  on  Abdominal  Tumors  (New  Syd.  Soc),  p.  224. 
Howison — Case   of  Sero-purulent   Distention   of  Kidney.     Edin.    Med.    Journ., 

1822,  p.  557. 
Basham— On  Dropsy.     3d  ed.     Lend.,  1866,  p.  348. 
Oppolzer — "Wiener  Med.  Wochenschr.,  1860. 
Todd — Clin.  Lects.  on  Dis.  of  Urin.  Organs.     Lond.,  1852. 
Chuckerbutty — Lancet,  1860,  ii. 
Mosler— Archiv  der  Heilkunde,  1863,  p.  420. 
Kussmaul — Wiirzb.  Med.  Zeitsch.,  1863,  p.  56. 


BIBLIOGRAPHY.  613 

Mackey— Brit.  Med.  Juurii  ,  J8G'J,  vol.  i.  p.  087. 

Stevens— Glasgow  Med.  Journ.,  1869,  p.  257. 

Michaelis— Zur  Lehre,  v.  d.  Pyol.  Wien.  Mod.  Presse,  vol.  xi.  33,  84. 

Wells,  S. — Dublin  Quart.  Journ.,  vol.  xliii.  p.  131. 

Pathological  Soc.  Trans.,  vol.  i.  j).  117;  x.  p.  209;   xix.  p.  278;   xxi.  p.  278;   xxi. 

p.  25. 
Charles— Brit.  Med.  Journ.,  March  20,  1875. 
Bbstein — Ziemssen's  Cyclop.,  Eng.  Trans.,  vol.  xv.  p.  562. 

CHAPTER  VII. 

Concretions  in  the  Kidneys. 

Eayer — Loc.  cit.  t.  iii.  p.  10. 

Virchow — Gesammelte  Abhandl.,  p.  833. 

Rosenstein — Loc.  cit.,  p.  425. 

Vogel — Krankh.  d.  Ilarnbereitend.  Organe,  p.'  684. 

Leroy  d'Etiolles  (flls) — Traite  prat,  de  la  Gravelle,  p.  235. 

Oppolzer— Wien  Med.  Presse,  vii.  27,  35,  36,  37. 

Eustace  Smith — Calculus  of  the  Kidney  in  Children,  Lancet,  1882,  i.  p.  266. 
Cases  of— See  Path.  Soc.  Trans  ,  xviii.  p.  181;  xix.  pp.  270,  281;  xxi.  p. 
253;  xxiv.  p.  148;  xxvi.  pp.  128  and  132;  xxix.  pp.  155  and  160;  Schmidt's 
Jahrb.,  Bd.  138,  S.  87 ;  Bd.  140,  S.  44 ;  Bd.  145,  S.  30.  Dub.  Quart.  Journ., 
vol.  1.  p.  481;  Lancet,  1873,  ii.  810;  1874,  ii.  695;  Ibid.,  1874,  ii.  1;  Med. 
Times  and  Gaz,,  1882,  p.  165. 

CHAPTEPv  VIII. 

Hydronephrosis. 
Glass^Phil.  Trans.,  1747. 

Johnson — Monthly  Med.-Chir.  Journ.,  1816  (July). 
Konig — Krankheiten  der  ISTieren.     Leipzig,  1826,  p.  152. 
Eayer — Maladies  des  Reins,  torn.  iii.  p.  476. 
Lee— Med.-Chir.  Trans.,  xix.  238. 
Hare— Med.  Times  and  Gaz.,  1857,  i.  29. 
Kussmaul— Wurzb.  Med.  Zeit.,  Bd.  iv.  Heft  I. 
Stadfeldt— (Etiology  of)  Monatsschr.  f.  Geburtsk.,  1862,  p.  69, 
Parre— Lancet,  1861,  ii.  472. 
Rosenstein — Nieren  Krankheiten,  2d  ed.,  352. 
Dumreicher — Wiener  Med.  Halle,  March  27,  1864. 
Strange — Beale's  Archives,  vol.  iii. 

Simpson,  A.  R. — Glasgow  Med.  Journ.,  New  Ser.  ii.  332. 
Friedreich— Virch.  Arch.,  vol.  69,  p.  308. 
Schottelius — Ibid.,  vol.  71,  p.  268. 
Morris — Med.-Chir.  Trans.,  vol.  lix.  p.  227. 
English— Zeitsch.  f.  Chirurg.,  Bd.  xi.  S.  11  and  252. 

See,  also— Path.  Soc.  Trans.,  vii.  262,  263,  265;  ix.  318;  xiii.  128,  137,  147, 

151 ;  xiv.  195;  xvi.  164  ;  xviii.  167,  171.    Brit.  Med.  Journ.,  1874,  ii.  401; 

1878,  ii.  p.  457.     Lancet,  1880,  i.  pp.  610  and  870.     Med.  Times  and  Gaz., 

1876,  i.  p.  546;  1882,  i.  p.  661.     Wien.  Med.  Wochenschr.,  April,  1876.. 

Virchow  and  Hirsch.  Jahresber.,  1880,  1881,  and  1882.     Gazette  des  Hopi- 

taux,  No.  30,  1882. 


614  BIBLIOGRAPHY. 

CHAPTEfl  IX. 

>    Cysts  and  Cystic  Degeneration  of  the  Kidneys. 

Eayer — Mai.  des  Keins,  t.  iii.  p.  507. 

Bright — Memoirs  on  Abdominal  Tumors  (New  Syd.  Soc),  p.  208. 

Hawkins — Med.-Chir.  Trans.,  xvii.  p.  175. 

Coote— Med.  Times,  1851,  ii.  p.  197. 

Virchow — Gesammelte  Abhandlungen,  pp.  837,  864. 

Siebold — Monatssch.  f.  Gerburtskunde,  1854. 

Beckmann — Archiv  f.  Path.  Anat. ,  ix.  p.  221. 

Forster — Pathol.  Anat.,  p.  357. 

Striibing— Deutsches  Arch.  f.  klin.  Medic,  Bd.  29,  S.  579. 

Path.  Soc.  Trans.— 1848-9,  p.  74;  1850-1,  p.  131 ;  1851-2,  pp.  377,  379,  384;  iv. 

pp.  193,  199;   V.  p.  183;  vi.  p.  267;  ix.  pp.  309,  334;  xix.  p.  274;  xxi.  p. 

244;  xxxi.  pp.  164  and  167.    See,  also,  Brit.  Med.  Journ.,  1883,  i.  p.  1177; 

and  Progres  Med.,  No.  20,  1883. 

CHAPTEE  X. 

Cancer  op  the  Kidney. 

Wilson— Dis.  of  Urin.  Organs.     Lond.,  1821,  p.  284. 

Otto — Neue  Beobachtungen  zur  Anat.  u.  Path.     Berlin,  1824. 

Konig — Krankh.  der  Nieren.     Leipz.,  1826,  p.  242. 

Langstaif — Med.-Chir.  Trans.,  vol.  vii.  p.  294. 

Bright — Memoirs  on  Abdominal  Tumors.     New  Syd.  Soc,  vol.  vi. 

Bayer — Mai.  des  Eeins,  t.  iii.  p.  675. 

Walshe — Nature  and  Treatment  of  Cancer.     Lond.,  1846. 

Lebert— Traite  d'Anat.  Path.     Paris,  1857,  vol.  ii. 

Kohler — Krebs-  und  Scheinkrebs-krankheiten.     Stuttgart,  1853,  p.  414. 

Basham — On  Dropsy,  3d  ed.,  p.  417. 

Doderlein — Inaug.  Diss.     Erlangen,  1860. 

Eosenstein — Nierenkrankheiten,  2d  ed.,  p.  403. 

Kussmaul— W-iirzb.  Med.  Zeitschr.,  1863,  p.  24. 

West — Diseases  of  Infancy  and  Childhood.     Lond.,  1852,  p.  490. 

Braidwood — Liverp.  Med.  Surg.  Eep.,  vol.  iv. 

Path.  Soc  Trans.,  i.  pp.  120,  281 ;  vii.  p.  268 ;  viii.  p.  286  ;  x.  p.  188 ;  xiv.  p.  179 ; 

xxi.  pp.  249,  252;  xxii.  p.  171  ;  Ibid.,  p.  173;  xxiv.  p.  149;  xxv.  p.  172; 

xxvi.  p.  132;  xxvii.  p.  204;  xxxiii.  pp.  195,  199,  219. 
Edin.  Med.  Journ.,  xvi.  p.  381 ;  xix.  p.  160;  New  Ser.  i.  p.  149. 
Journ.  f.  Kinderkrankh.,  xxix.  p.  396;  xxxv.  p.  426;  xxxvii.  p.  292. 
Perewerseff — Virchow's  Archiv.,  lix.  p.  227. 
Neumann — Essai  sur  le  Cancer  du  Eein.     Paris,  1873. 
Lancet,  1873,  i.  p.  131 ;  and  Ibid.,  1874,  ii.  p.  49 ;  1877,  i.  pp.  194  and  567 ;  Brit. 

Med.  Journ.,  1881,  i.  p.  806. 
Kiihn — Deutsches  Arch.  f.  Klin.  Medic,  xvi.  p.  806. 
Weigert — Virch.  Archiv,  vol.  Ixvii.  p.  423. 
Eohrer— Ibid.,  p.  492. 
Cattani — See  Yirch.  and  Hirsch.  Jahresber.,  1882,  ii.  p.  194;  also  see  Ibid.,  1883, 

ii.  p.  221 ;  and  Progres  Med.,  1883,  No.  20. 


BlBLlOGKArHY.  616 

CHAPTEK  XI. 

Bknion  Gkowth«  in  tub  KrnNEY. 

Rayer — Mai.  des  Eeins,  iii.  605. 

Godard— Substitution  graisseuse  du  Kein.     Paris,  1859. 

Virchow — Gesammelte  Abhandlung«n,  p.  208. 

Heath— Adipose  Transformation  of  the  Kidney.     Path.  Soc.  Trans.,  x.  199. 

Dickinson— Fibro-fatty  Tumor  of  the  Kidney.     Path.  Soc.  Trans.,  xiv.  187. 

Bristowe — A  Tumor  of  the  Kidney.     Ibid.,  p.  189. 

Wilks— Fibrous  Tumor  of  the  Kidney.     Path.  Soc.  Trans.,  xx.  224. 

Wagner— Archiv  der  Heilkunde,  1860,  Heft  iv. 

Friedreich— Archiv  f.  Path.  Anat.,  Bd.  xii. 

Bottcher — Ibid.,  Bd.  xiv. 

CHAPTER  XII. 

Tubercle  of  the  KiDNisY. 

Rayer — Mai.  d.  Reins,  t.  iii.  p.  618. 

Carswell— Pathological  Anatomy,  pi.  ii.  tig.  5. 

Basham— On  Dropsy,  3d  ed.,  384. 

Rosenstein — Nierankrankheiten,  2d  ed.,  p.  387. 

Rilliet  and  Barthez— Malad.  des  Enfans,  t.  iii.  p.  852. 

Chambers— Decennium  Pathologicum.     Med.  Times  and  Gaz.,  1852,  ii.  403. 

Schmidtlein— Ueber  die  Diagnose  d.  Phthisis  Tuberculosa  der  Harnwege.   Deutsche 

Klinik,  1863. 
Kussmaul— Beitrage  zur  Anat.  u.  Path.  d.  Harnapparats.   Wiirzb.  Med.  Zeitsch., 

Bd.  iv.  S.  24. 
'  Mosler— Beitrage  zur  Path.  u.  Therap.  d.   Krankh.  d.  Harnwege.     Archiv  d. 

Heilkunde,  1863,  p.  299. 
Colin— Nephrite  Tuberculeuse  aigue.     Gaz.  Hebd.,  t.  x.  p.  39. 
Southey— Brit.  Med.  Journ  ,  1867,  i.  p.  444. 
Ellis— Ibid.,  1869,  ii.  p.  324. 
McDowell— Ed.  Med.  Journ.,  xv.  p.  1093. 
Klob— Oester.  Zeitsch.  f.  pract.  Heilk.,  xiv.  9,  10. 
Cases-Schmidt's  Jahrb.,  Bd.  140,  S.  44;  and  Ibid.,  Bd.  144,  S.  219.     Virchow 

and  Hirsch's  Jahresbericht,  1876,  ii.  p.  232;  1877,  ii.  p.  228;  1880,  ii.  p. 

212;  1881,  ii.  p.  205. 
Tapret— Archiv  Gen.  de  Med.,  May  and  July,  1878. 
Bierry — These  de  Paris,  1878. 
Jean — France  M6dicale,  1878. 
Picard— Gaz.  Hebdom.,  1879,  No.  27. 
Gaultier— These  de  Paris,  1882. 

CHAPTER  XIII. 
I. — Hydatids  in  the  Kidneys. 
Chopart— Traite  des  Malad.  des  Yoies  Urinaires.     Ed.  by  Segalas.     Paris,  1855. 
Rayer — Malad.  des  Reins,  t.  iii.  p.  545. 
Barker— On  Cystic  Entozoa  in  the  Human  Kidney.     Lend.,  1856. 


616  BIBLIOGRAPHY. 

Davaine — Traite  des  Entozuaires.     Paris,  1860,  p.  524. 

Gervais  and  Van  Beneden — Zoologie  Medicale.     Tom.  ii.  274. 

Beraud — Hydatides  des  Keins.     Paris  Thesis,  1861. 

Curling— Med.  Times  and  Gaz.,  1863,  ii.  164. 

Collection  of  cases  in  Med.  Times  and  Gaz.,  Peb.  17,  1855. 

Sieveking — Lancet,  Sept.  10,  1853. 

Simon— Ibid.,  Sept.  24,  1853. 

Durand — Assoc.  Medical  Journal,  March,  1851. 

Tomowitz— Schmidt's  Jahrb.,  Bd.  116,  S.  200. 

Quinquerez — Ibid. 

Meissner — Beitrage  zur  Lehre  von  dem  Yorkommen  des  Echinococcus  beim 
Menschen.     Schmidt's  Jahrb.,  Bd.  116,  S.  188. 

Adams  (Dr.  Leith)— Lancet,  Oct.  1,  1864. 

Cobbold — Parasites.     London,  1879,  p.  112. 

Simon — Die  Echinococcus-Cysten  der  Nieren.     Stuttgart,  1877. 

Eomestan — These  de  Paris,  1881. 

Cases— Gaz.  Hebd.,  1868,  p.  702;  Schmidt's  Jahrb.,  Bd.  146,  S.  292.  Mouvement 
Medical,  Nov.  9,  1872.  Path.  Soc.  Trans.,  xxv.  p.  173;  xxix.  p.  155;  Vir- 
chow  and  Hirch.  Jahresber.,  1878,  ii. ;  St.  Bart.'s  Eeports,  vol.  xii.  p.  255. 

II. — BiLHARZIA  HiEMATOBIA. 

Bilharz — Zeitsch.  fiir  Wissenschaftliche  Zoologie.     Bd.  iv. 

Griesinger — Beobachtungen   liber  die   Krankheiten   von    Egypten.      Archiv   d. 

Physiolog.  Heilk.     1854,  p.  561. 
Davaine — Entozoaires.     Synopsis,  No.  38. 
Cobbold — Parasites,  p.  38. 
Harley  (Dr.  John) — Endemic  Hematuria  of  the  Cape  of  Good  Hope.    Med.-Chir. 

Trans.,  vol.  47,  p.  55;  Ibid.,  vol.  52;  and  Ibid.,  vol.  54. 

III. — FiLARiA  Sanguinis  Hominis. 

Lewis — On  a  Hajmatozoon  in  Human  Blood.    Calcutta,  1874.    Also  Lancet,  1877, 

ii.  p.  453. 
Bancroft— Path.  Trans.,  vol.  xxix.  p.  407;  Lancet,  1877,  ii.  p.  70. 
Cobbold — On  Parasites.     London,  1879,  p.  180. 
Manson — Filaria  Sanguinis  Hominis.     London,  1883. 

Wykeham  Myers — Med.  Eeport  of  Inspector-General  of  Customs.     China,  1881. 
Sonsino  —Med.  Times  and  Gazette,  i.  1882. 
Mackenzie — Path.  Trans.,  vol.  xxxiii.  p.  394. 

IV. — Strongtltts  Gigas. 

Davaine — Entozoaires.     Synopsis  99,  and  p.  267. 
Cobbold — Parasites,  p.  208. 

V. — Pentastoma  Denticulatum. 

Davaine — Entozoaires,  pp.  Ixxxviii.  and  293. 

Wagner — Archiv  der  Physiologische  Heilkunde.     1862,  p.  681. 

Cobbold — Parasites,  p.  259. 


BIBLIOGRAPHY.  G17 


CHAPTER  XIV. 

Anomaliks  op  Position,  Form,  anjj  Numbicr  of  the  Kidnkys. 

Chopart — Malad.  d.  Voies  XJrinaires     Edit,  by  S('ga]as.     Paris,  18')"),  p.  -vS. 

Rayer — Malad.  d.  Reins,  t.  iii.  769. 

Durham — Guy's  IIosp.  Reports,  1860,  p.  404. 

Rosenstein — Nierenkrankheiten.     2d  ed.,  474. 

Vogel — Krankh.  d.  Ilarnbcreitonden  Organe.     Erl.,  IHG^j,  p.  706. 

Klebs— Handb.  d.  Path.  Anat.,  p.  604. 

Ebsteiri — Ziomssen's  Cyclop.,  Eng.  Trans.,  vol.  xv.  p.  761. 

Ziegler— Lehrbuch  d.  Path.  Anat.,  1883,  2d  vol.,  p.  391. 

Beamer — See  Lancet,  1878,  i.  p.  581.  ' 

Movable  Kidneys. 

Hare— Med.  Times  and  Gaz.,  1858,  i.  p.  7  ;  and  1860,1.  p.  30 

Oppolzer — Ibid.,  1857,  i.  575;  and  Clin.  Europ.,  1859,  No.  2. 

Fritz — Archives  Generales,  Aug.  and  Sept.  1859. 

Henoch— Klinik.  d.  Unterleibs-Krankh.     Berlin,  1858.     Bd.  iii.  S.  367. 

Becquet — Archives  Generales,  Jan.  1865. 

Dietl— Wiener  Med.  Woch.,  1864,  p.  563. 

Rollet— Path.  u.  Therap.  d.  Beweg.  Niere.     Erlane-.,  1866. 

Sawyer — Floating  Kidney.     Bi'i-mingham  Med.  Rev. 

Landau — Die  Wanderniere  der  Frauen.     Berlin,  1881.     See,  also,  Med.  Times 

and  Gaz.,  1882,  i.  p.  202. 
Report  of  Committee  of  Pathological  Society.     Path.  Trans.,  xxvii.  p.  467. 
Newman — On  Malpositions  of  the  Kidney.     Glasgow  Medical  Journal,  August, 

1883  ;  where,  also,  a  complete  account  of  the  literature  will  be  found. 
Cases— See  Lancet,  1862,  ii.  p.  139  ;- 1863,  i.  p.  521;  ii.  p.  363;   1872,  ii.  p.  713; 

Med.  Times  and  Gaz.,  1857,  p.  651 ;  1858,  i.  p.  331 ;  ii.  p.  36  ;  1859,  ii.  p. 

426;   1860,  i.  p.  9;  1864,  July  9;  1872,  ii.  p.  328;  Midland  Joiirn.,  Jan. 

1858;  Prag.  Vierteljahrschr.,  Bd.  51;  Yirchow's  Archiv,  Bd.  Iii.  S.  95; 

Berl.  Klin.  Wochenschr.,  1866,  iii.  p.  41 ;  Brit.  Med.  Journ.,  1869,  i.  541 ; 

ii.  p.  211 ;  1870,  i.  p.  35;  1874,  i.  p.  453;  Path.  Soc.  Trans.,  xvii.  p.  165; 

Glasg.  Med.  Journ.,  1870  (New  Series),  ii.  553. 


INDEX  OF  SUBJECTS. 


ABSCESS  of  the  kidney,  449 
Abscesses,  multiple,  in  the  kidney, 
451 
Acid  of  the  urine,  77 
Albumen  in  the  urine,  185 
forms  of,  185 
tests  for,  186 

quantitative  estimation  of,  190 
clinical  significance  of,  194 
causes  of,  194 
Albuminuria,  functional,  196 
permanent,  198 
experiments  on  the  production  of, 

199,  358 
in  diabetes,  250 

in  connection  with  pregnancy,  371 
saturnine,  195 
neurotic,  197 
pathology  of,  199 
Alkaline  urine,  from  ammonia,  82 
from  food,  77 
from  medicines,  80 
from  the  cold  bath,  81 
from  disease,  81 
Amblyopia  in  Bright's  disease,  418,  429 

in  diabetes,  255 
Ammoniacal  urine,  82 
Amyjoid  degeneration  of  the   kidneys, 

404 
Amyloid  substance  in  the  liver,  265 
Anazoturia,  223 

Anomalies  of  position  of  the  kidneys,  587 
form  of,  604 
number  of,  605 
Apparatus  for  urine  testing,  36 
Azoturia,  131 

BACILLUS  of  tubercle  in  urine,  555 
Bacteruria,  177 

Baruria,  note,  131 

Bile  in  urine,  tests  for,  47 

Bilharzia  ha^matobia,  575 

Blood  in  urine.     See  Hematuria. 
tests  for,  150 

Bran  cakes,  273 

Bright's  disease — general,  376 
classification  of,  377 
general  etiology  of,  379 
oneness  or  multiformity  of,  403 
secondary  affections  in,  419 


Bright's  disea.se — acute,  383 

anatomical  characters  of,  383 

course  and  symptoms  of,  386 

diagnosis  of,  391 

prognosis  of,  392 

etiology  of,  392 

treatment  of,  393 
Bright's  disease — chronic,  396 

anatomical  changes  in  the  kid- 
neys in,  396 

granular  kidney  in,  399 

smooth  white  kidney  in,  396 

lardaceous  kidney  in,  404 

course  and  symptoms  of,  407 

duration  of,  409 

urine  in,  414 

dropsy  in,  417 

pulse  in,  418 

retina  in,  418 

complications  of,  419 

and  phthisis,  420 

and  cardio-vascular  changes, 424 

diagnosis  of,  437 

prognosis  of,  439 

treatment  of,  441 

riALCULUS,  indigo,  309 
\J         urinary,  292 

general  etiology  of,  292 
Calculi,  urinary,  294 

classification  of,  294 
origin  and  growth  of,  296 
varieties  of,  297 
diagnosis  of  species  of,  309 
medical  treatment  of,  311 
preventive  treatment  of,  811 
solvent  treatment  of,  315 
renal.  .SeeConcretionsintheKidneys 
blood  and  fibrinous,  307 
prostatic,  309 
Cancer  of  the  kidney,  514 
primary,  514 

morbid  anatomy  of,  514 
etiology  of,  518 
symptoms  and  signs  of,  519 
hjematuria  in,  521 
diagnosis  of,  538 
duration  of,  522 
treatment  of,  536 
secondary,  586 


620 


INDEX    OF    SUBJECTS. 


Cancerous  matter  in  urine,  170 

Carboluria,  48 

Carbonate  <if  lime  in  urine,  123 

■  calculi,  303 
Casts  of  tubes,- 138 

clinical  significance  of,  141 

formation  of,  141 
Cataract,  diabetic,  255 
Chlorine  and  the  chlorides,  124 

excretion  of,  124 
Cholesterine  in  urine,  144 
Chylous  urine,  335 

cases  of,  338 

course  of,  337 

etiology  of,  344 

pathology  of,  345 

treatment  of,  355 

filarias  in,  353 
Colic,  nephritic,  475 
Color  of  the  urine,  42 
Coma,  diabetic,  257 
ursemic,  430 
diagnosis  of,  432 
Composition  of  the  urine,  34 
Concretions  in  the  kidneys,  474 

in  new-born  infants,  474 

symptoms  of,  475 

diagnosis  of,  476 

treatment  of,  477 
Congestion  of  the  kidneys,  357 

experimental  researches,  358 

active,  360 

passive,  365 

connection  of,  with  pregnancy 
and  eclampsia,  371 
Confervoid  growths  in  the  urine,  175 
Convulsions,  puerperal,  urine  in,  371 

ursemic,  430 
Creatine  and  creatinine,  115 
Cystine  in  urine,  106 
calculi,  300 

solvent  treatment  of,  333 
Cysts  in  the  kidney,  501,  504 
Cystic  degeneration  of  the  kidneys,  504 
congenital,  502 
in  adults,  504 

DETSTSITY  of  the  urine,  49 
Deposits  in  the  urine,  36,  86,  184 
Diabetes  insipidus,  223 

etiology  of,  224 

course  and  symptoms  of,  226 

duration  of,  229 

morbid  anatomy  of,  230 

cases  of,  230 

nature  of,  236 

diagnosis  of,  239 

prognosis  of,  239 

treatment  of,  239 

with    minute   traces   of  sugar, 
241 
Diabetes  mellitus,  243 


Diabetes  mellitus,  etiology  of,  244 

symptoms  of,  248 

course,  duration,  termination  of, 
253 

complications  of,  254 

morbid  anatomy  of,  260 

theoretical  considerations  on  ,264 

diagnosis  of,  270 

prognosis  in,  270 

treatment  of,  272 
Diabetes,  artificial,  267 
intermittent,  288 
milder  types  of,  286 
Diabetic  cataract,  255 
amblyopia,  255 
coma,  257 
Distoma  haematobium,  575 
Dropsy  of  the   kidney.     See  Hydrone- 
phrosis. 
Earthy  phosphates,  deposits  of,  117 
Echinococci.     See  Hydatids. 
Eclampsia,  urine  in,  371 
Eijtibolism,  renal,  452 
Entozoa  in  the  kidneys,  558 
Epithelium  in  urine,  extrarenal,  134 

renal,  137 
Examination  of  the  urine,  35 
Extirpation  of  kidney,  478 
Extraneous  matters  in  urine,  37 
Extractives  of  the  urine,  34 

FATTY  concretions,  301 
Fatty  matters  in  urine,  143 
Fehling's  sugar  test,  208 
Fermentation,  acid  urinary,  40 

ammoniacal,  40,  83 

test  for  sugar,  206,  218 
Ferments  in  the  urine,  note^  38 
Fibro-fatty  tumors  of  the  kidney,  541 
Filaria  sanguinis  hominis,  353,  581 
Filarial  periodicity,  353,  583 
Food,  effect  of,  in  the  urine,  61 
Fungi  in  the  urine,  175 
Fusible  calculus,  306 

GANGRENE,  diabetic,  2-54 
Glycosuria.      See   Sugar   in    the 
Urine,  and  Diabetes. 
Gluten  bread,  274 
Gravel.     See  Calculus. 
Growths,  benign,  of  the  kidneys,  541 
Guanine,  115 

H^MATINURIA,  157 
Hsemoglobinuria,  157 
Hsemoglobinuria,  paroxysmal,  158 
symptoms  of,  158 
character  of  the  urine,  158 
cases  of,  162 
etiology  of,  166 
pathology  of,  167 
treatment  of,  169 


INDEX    OF    SUBJECTS, 


621 


Hasrnaturia,  148 

classification  of,  150 
endemic,  153,  577 
diagnosis  of  source,  150,  154 
symptomatic,  154 
supplementary,  155 
renal,  150 

in  cancer  of  the  kidney, ,520 
treatment  f)f,  155 
from  rupture  of  the  kidney,  151 
Hepatine,  265 
Horseshoe  kidney,  604 
Hydatids  in  the  kidney,  558 

natural  history  of,  558 
morbid  anatomy  of,  561 
cases  of,  568 
symptoms  of,  566 
etiology  of,  672 
diagnosis  of,  572 
treatment  of,  574 
Hydatids  voided  with  the  urine,  561 
Hydronephrosis,  479 

morbid  anatomy  of,  479 
etiology  of,  484 
symptoms  of,  492 
terminations  of,  494 
diagnosis  of,  495 
treatment  of,  496 
Hydrorenal   distention.     See  Hydrone- 
phrosis. 
•  Hypoxan  thine,  115 
Hysterical  anuria,  56 

TMPUKITIES  in  the  urine,  87 

1     Indican,  46 

Indigo,  46 

Indigo-carmine  test  for  sugar,  212 

Inorganic  deposits  in  urine,  86 

Inosite,  227 


J 


AUNDICE,  urine  in,  47 


jrlESTINE,  147 

T  EUCINE  in  urine,  114 

Ju     Lime,  carbonate  of,  123,  303 

phosphates  of,  118,  119 
Lithates.     See  Urates. 
Lithic  acid.     See  Uric  Acid. 
Lymphatic  growths  in  the  kidney,  542 
Lymphous  urine,  336 

MAGNESIA,  phosphate  of  ammonia 
and, 122 
Malformations  of  the  kidney,  604 
Malpositions  of  the  kidney,  587 
Melanuria,  159 

Microdrganisms  in  the  urine,  175 
saccharomyces,  174 
sarcina,  176 


iVI  icrdurguni.siiiH  in  t(i';   urine — bucteria, 

177 
Misplacements  of  the  kidney,  587 
Moore's  test  for  sugar,  205 
Movable  kidneys,  591 

physical  signs  and  -iy  mptoni.s,  59 1 

cases  of,  593 

etiology  of,  599 

diagnosis  of,  602 

treatment  of,  602 
Mould  fungus  in  urine,  175 

NEPHRITIC  colic,  475 
Nephritis.      See   Bright's    Disease 
and  Congestion. 
Nephrotomy,  478 
Nephrectomy,  478 
Neurotic  albuminuria,  197 

OIL.     See  Patty  Matters  in  the  Urine. 
Optical  saccharimetry,  221 
Organic  deposits,  86,  134 
Osseous  growths  in  the  kidney,  541 
Ossification  in  the  kidneys,  456 
Oxalate  of  lime,  deposits  of,  99 

clinical  significance  of,  102 
treatment  of,  105 
calculi,  299 

solvent  treatment  of,  333 
Oxalic  diathesis,  103 
Oxaluria,  103 

PAEASITES  in  the  kidney,  558 
Penicilium  glaucum,  175 
Pentastoma  denticulatum,  585 
Phosphates,  earthy,  in  the  urine,  117 
amorphous,  118 
crystallized,  119  ■ 
stellar,  119 
triple,  121 

ammoniaco-magnesian,  122 
secondary,  295 
mixed,  295 
Phosphatic  calculi,  295 

solvent  treatment  of,  334 
Phosphoric  acid  and  the  phosphates,  115 
Phosphorus,  excretion  of,  116,  124 
Picric  acid  test  for  sugar,  213 
Pigments  of  the  urine,  42 
Polydipsia,  223 
Polyuria,  223 
Pregnancv,  a  cause  of  Bright's  disease, 

373 
Pregnancy,  urine  in,  146,  371 
Prostatic  calculi,  309 
Protocatechuic  acid  in  the  urine,  45 
Puerperal  eclampsia,  urine  in,  373 
Purulent  casts  in  the  urine,  139 

note^  449 
Pus  in  urine,  146 
j  diagnosis   of    source   of,    147.     See 

I  Pyelitis. 


622 


INDEX    OF    SUBJECTS. 


Pyelitis,  455 

morbid  anatomy,  455 
etiology  of,  456 
symptoms  of,  459 
cases  of,  461 
diagnosis  of,  467 
prognosis  of,  469 
treatment  of,  470 

Pyelo-nephritis,  456 

Pyonephrosis,  454 

Pyrocatechin,  45 


Q 


TJANTITY  of  the  urine,  50 


REACTION  of  the  urine,  76 
Eemoval  of  kidney,  478 
Retinitis  in  Bright's  disease,  418,  429 

QACCHAEIMETRY,  optical,  221 

U     Sarcinse  in  urine,  176 

Sarcoma  of  the  kidney,  539 

Saturnine  albuminuria,  195 

Solids  of  the  urine,  50 

Solid  urine,  51 

Solitary  kidney,  605 

Solvent   treatment  of    urinary    calculi, 

315 
Specific  gravity  of  the  urine,  49 
Spermatozoa  in  urine,  171 
Spermatorrhoea,  171 

treatment  of,  173 
Stone.     See  Calculus. 
Strongylus  gigas,  584 
Sugar  in  the  urine  {see  also,  Diabetes), 
204 
tests  for,  qualitative,  205 

quantitative,  213 
clinical  significance  of,  221,  243 
classification  of  cases  of,  243 
physiological  considerations  on, 
264 
formation  of,  in  the  liver,  265 
fungus  in  the  urine,  175 
Sulphuric  acid  and  the  sulphates,  123 
Sulphur,  excretion  of,  124 
Suppression  of  urine,  54 

non-obstructive,  54 
obstructive,  57 
causes  of,  57 
symptoms  of,  59 
cases  of,  60 
treatment  of,  75 
Suppuration  in  the  kidney,  449 
Surgical  kidney,  458 
Syphilitic  deposits  in  the  kidney,  542 

TOEUL^  in  urine,  175 
Trommer's  test  for  sugar,  208 
Tubercle  of  the  kidney,  544 


Tubercle  of  the  kidney,  comparative  fre- 
quency of,  544 
primary,  544 

morbid  anatomy  of,  544 
etiology  of,  546 
symptoms  of,  546 
cases  of,  548 
diagnosis  of,  554 
treatment  of,  555 
secondary,  556 
Tuberculous  matter  in  the  urine,  170 
Tumors  of  the  kidney,  541.     See   also 
Cysts,  Hydronephrosis,  Cancer,  Hy- 
datids, Pyonephrosis. 
Tyrosine  in  urine,  114 

UEATE  concretions,  298 
Urate  of  ammonia,  94,  98 
of  soda,  94,  97 
Urates,  amorphous,  94 

crystalline,  97 
Uraemia,  428 

symptoms  of,  429 
theories  of,  434 
treatment  of,  441 
Urea,  125 

excretion  of,  in  health,  126 

in  disease,  130 
pathology  of,  130 
estimation  of  quantity  of,  126 
Urian,  43 
Urianine,  43 
Uric  acid,  87 

deposits  of,  87 
daily  excretion  of,  91 
estimation  of  quantity  of,  90 
origin  and  occurrence  of,  91 
clinical  significance  of,  92 
Uric  acid  calculi,  297 

solvent  treatment  of,  317 
Urobilin,  43 
Urochrome,  46 
Urolithiasis.     See  Calculus. 

YEGETATIONS  in  the  urine,  175 

WAXY  degenerations  of  the  kidneys, 
404 
Worms,  erratic,  585 
spurious,  586 

yANTHINE,  111 


yEAST  fungus,  175 
yOOAMYLUM,  265 


INDEX  OF  AUTHORS. 


A  BEILLE,  371 
A     Abele,  516 
Ackermann,  337 
Adamkiewicz,  284 
Adams,  168 
Adams,  J.,  600 
Adams,  K.,  303 
Allbutt,  68,   419 
Althaus,  241 
Apjohn,  128 
Aufrecht,  364 
Axel  Key,  141 

BABES,  555 
Babington,  569 
Baillie,  565 

Bamberger,  197,  203,  369,  429 
Bancroft,  345,  363,  582 
Barker,  570 
Barlow,  393 
Barreswil,  196 
Bartels,  139,  403 
Barthez,  544 
Basham,  155,  546 
Baumann,  48 

Beale,  110,  116,  144,  261,  299,  340 
Beckmann,  453 
Becquerel,  191,  240,  253 
Becquet,  591,  600 
Begbie,  103,  197,  336 
Bence-Jones,  77,  81,  95,  112,  116,  186, 

188,  205,  286,  289,  353,  336,  337,  345 
Beneden,  van,  560 
Benedikt,  175 
Beneke,  77,  104,  196 
Bennett,  Sir  E.,  548 
Bennett,  Dr.,  226,  555 
B^raud,  562 
Bergson,  369 

Bernard,  167,  197,  201,  238,  261,  264 
Beumer,  606 
Bidder,  126 
Biermer,  433 
Bilharz,  153,  575 
Billiard,  255 

Bird,  44,  95,  100,  103,  107,  112,  174 
Birkett,  561 
Birch-Hirschfeld,  515 


Bischofif,  126 

Blackall,  382 

Blackburn,  572 

Blot,  873 

Boas,  160 

Bodecker,  45,  191 

Bottcher,  542 

Bouchardat,  255,  274,  286 

Bouillaud,  363 

Bowen,  144 

Bowman,  200,  377 

Braconnot,  46 

Bradley,  543 

Brandt,  478 

Brault,  384 

Braun,  373 

Brieger,  259 

Bright,  376,  424,  430,  444,  516,  520 

Brinton,  535 

Bristowe,  504,  541 

Broadbent,  418,  426 

Brodie,  307 

Browne,  542 

Brown-Sequard,  196 

Browicz,  364 

Bruce,  201,  442 

Briicke,  33,  205 

Brunton,  201,  446 

Buchheim,  80 

Budd,  286 

Buhl,  427 

Bunyan,  355 

Burd,  286 

Byl,  Van  der,  533 

pAFFE,  468 

\J     Cameron,  124 

Campbell,  478 

Camplin,  273,  275 

Cantani,  272,  285 

Canton,  588 

Carmichael,  254 

Carrere,  76 

Carsweil,  515 

Carter,  46,  98,  296,  299,  345 

Cattani,  515 

Chambers,  175,  451,  544,  556 

Champoiullon,  255 


624 


INDEX    OF    AUTHORS. 


Charcot,  56,  195 

Chevallier,  316 

Christison,  201,  881,  389,  443,  444 

Chopart,  155,  568 

Chotinsky,  513 

Civiale,  110,  301,  380 

Clarke,  Sir  A.,  56 

Cloetta,  106 

Cobbold,  588 

Cohn,  83,  178 

Cohnheim,  358,  454,  540 

Colin,  556 

Colles,  254 

Cook,  90 

Cornil,  141,  200,  364,  869,  384,  542 

Cruveilhier,  600 

Cubitt,  337 

differ,  436 

Cullingworth,  458 

Curling,  586 

DANJOY,  195 
Davaine,  558,  584 
Davy,  303 
Day,  592 
Debove,  427 
Deiohmuller,  259 
Delavaud,  77 
Demange,  133 
Desir,  382 
Dessler,  158 
Devilliers,  373 
Dewar,  108 
Dicenta,  175 
Dickinson,  158,  196,  235,  244,  261,  372, 

385,  400,  483,  541 
Dittrich,  546 
Dompeling,  247 
Donkin,  282 

Dreschfeld,  157,  175,  257,  259,  263,  539 
Duckworth,  102,  199 
Duffey,  503 
Duigan,  68 
Dukes,  196 
Dulk,  48,  112 
Dumreicher,  483 
Duncan,  225,  245 
Dunin,  364 
Dupaul,  374 
Durham,  590,  591 
Durian,  81 
Dutt,  338 

EADE,  230 
Ebstein,  45,  109,  146,  260,  301,  474 
Eckhard,  228,  238 
Edlefsen,  196 
Egger,  337 

Ehrlich,  160,  261,  264 
Elliotson,  841,  541 
Elliott,  371 
Eschricht,  572 


Evans,  504 
Eve,  540 
Ewald,427 

FABER,  481 
Fabre,  111 
Fagge,  515 
Falck,  227,  252 
Farre,  586 
Fawdington,  45 
Fayrer,  56,  245 
Fazio,  236 
Fehr,  406 
Feltz,  436 

Fischer,  241,  247,  256 
Fitz,  259 
Fiaischlen,  372 
Flatten,  238 
Fleckels,  573 
Fleischer,  166 
Fleming,  519 
Forrest,  160 
Forster,  261 
Foster,  259 
Fourcroy,  316 
Fraentzel,  161 
France,  255 

Frank,  155,  226,  289,  254 
Frankel,  115 
Eraser,  259 
Frerichs,   114,   203,  248,  259,  261,  359,, 

369,  873,  377,  889,  403,  417,  435,  585 
Friedliinder,  886 
Friedreich,  542 
Fritz,  247,  591 
Fiirbringer,  123,  196 
Finlayson,  142 
Fynney,  561 

GAMGEE,  108,  263 
Galabin,  426 
Gallippe,  189 

Garrod,  76,  93,  102,  251,  273 
Gay,  572 
Gayet,  238 
Gerhardt,  258 
Germont,  358 
Gilewsky,  593 
Girard,  253 
Glass,  482 
Godard,  542 
Golding,  146 
Gombault,  195 
Goodhart,  263 
Goolden,  247,  254 
Gorup-Besanez,  389 
Gosset,  345 
Gottwalt,  203 
Gowers,  186,  255,  418 
Graefe,  v.,  255,  429 
Graves,  83 
Grawitz,  425 


INDEX    OF    AUTHORS. 


625 


Gray,  284,  512 

Green halgh,  r)3,5 

Greenhow,  \hS 

Gregory,  22(i 

Grie.-inger,  153,  253,  2(i(),  261,  2(;4, 

284,  28G,  288,  575 
Griilziier,  38 
Guer?ant,  256 
Guiboiit,  345 
Gull,  158,  197,  401,  426,  502 

HAAS,  236 
Habershoii,  335 
Hagen,  222 
Haidane,  303 
Hamburger,  395 
Hamilton,  259,  415 
Hammond,  91,  435 
Harcourt,  90,  331 
Hare,  485,  501,  591 
Harley,  G.,  46,  47,  158,  263,  266 
Harley,  J.,  153,  577 
Hassall,  95,  119 
Hawkins,  501,  530 
Havem,  167 
Heidenhain,  200,  203 
Heller,  44,  46,   80,   150,  176,  275, 

298,  302,  314,  389,  443 
Hernitz,  122 
Henderscin,  148 
Henninger,  472 
Henoch,  591 
Henry,  213 
Hensiey,  220 
Hepp,  256 

Hermann,  58,  202,  359 
Heriich,  523 
Heschl,  585 
Hevin,  478 
Hicks,  146 
Hiller,  371 
Hillier,  498,  606 
Hilton,  174 
Hodgkin,  255 
Hoifmanii,  115 
Hohl,  590 
Hoogeweg,  474 
Houghton,  238 
Hounsell,  530 
Howison,  463 
Hoyle,  515 
Hunstone,  303 

TRVINE,  263 
i     Isaacs,  336,  344 
Israel,  425 
Iwanotf,  205 

TACCOUD,  430,  436 
eJ     Jackson,  118 
Jatfe,  48,  47 


296, 


Jaksch,  von,  258 
James,  486 

Johnson,   139,   189,    197,   2i;i    217.  368. 
377,  400,  426,  449,  592 
275,    Jones,  545 
Jonge,  247 
Jurin,  322 

KAMUTZ,  238 
Kekule,  405 
Kelly,  604 
Kennedy,  240 
Keppler,  603 
Kien,  235 
Kirkes,  453 
Klebs,  386,  450 
Klein,  384,  400 
Knapp,  215 
Knoll,  288 
Kohler,  528 
Koster,  504 
Kiihne,  186 

Kiilz,  227,  228,  241,  263 
Kupfer,  504 

Kussmaul,  257,  469,  554 
Kiissner,  167 

T  AFFONT,  269 

JL     Lallemand,  174 

Lanc^reaux,  195,  261,  542 

Landouzy,  245,  255 

Landau,  591 

Langhans,  141 

Langier,  112 

Langs tatf,  520 

Latham,  287 

Latour,  155 

Lawrence,  582 

Laycock,  56,  197 

Leared,  102 

Lebert,  519,  528 

Lecorche,  255,  256 

Leech,  886,  550,  606 

Legg, 158 

Legrand  dn  Saulle,  257 

Lehmann,  113,  201 

Lenoir,  301 

Lepine,  160,  201 

Lettsom,  568 

Letulle,  427 

Leube,  196 

Leubuscher,  285 

Lever,  502 

Lewinski,  425 

Lewis,  353,  581 

Leyden,  863,  372,  404,  427 

Lichtheim,  160 
i  Liebermeister,  444 
I  Liebig,  111,  126 

Litten,  384 
j  Litzmann,  373 
40 


626 


INDEX    OF    AUTHORS. 


Livois,  566 
Lobisch,  110 
Logan,  259 
Ludwig,  58,  425 
Lundberg,  546 
Lusk,  266 
Luys,  261 

MCDONNELL,  267 
Mackay,  176 
Mackenzie,  160,  337,  353,  588 
Maclagan,  112 
MacMunn,  43 
Magawley,  80 
Magendie,  313 
Magitot,  252 

Mahomed,  203,  387,  418,  427,  436 
Maly,  43 
Manson,  583 
Manzolini,  519 
Marcet,  48,  111,  301,  807 
Marchal  de  Calvi,  254 
Marechal,  47 
Marowski,  109 
Marsh,  245,  254 
Martin,  474 
Mascagni,  320 
Mascarel,234 
Maxwell,  228 
Medd,  456 
Meissner,  186,  566 
Mesu^,  591 

Mettenheimer,  143,  157 
Meyer,  359,  373 
Miahle,  283 
Moleschott,  285 
Monneret,  261 
Montgomery,  146 
Moore,  206,  430,  521 
Moore,  N.,  515 
Moore,  W.,  302 
Morgan,  de,  514 
Morison,  247,  335 
Morris,  500 
Mosler,  235,  417,  546 
Moxon,  196,  542 
Mulder,  212 
Muller,  45 
Miiller,  212,  263 
Muller- Warneck,  592 
Miinch,  407 
Munk,  176,  363 
Mvirchison,  145,  202,  514 
Murrell,  240,  286 
Murri,  160 

NASSE,  265 
Nauche,  146 
Nelson,  284 
Neubauer,  122 
Neuffer,  231 


Neufoille,  605 
Neiischler,  227 
Newman,  202,  603 
Niemann,  109 
Norris,  45 
Nothnagel,  142     , 
Nussbaum,  200 

/ADLING,  48 

U     Oliver,  144,  188,  189,  212 

Ollivier,  195 

Oppler,  435 

Oppolzer,  157,  443,  591 

Ord,  88,  296,  306,  309,  345 

Orsi,  226 

Overbeck,  202,  359 

PAGET,  75 
Paolucci,  542 
Parkes,  50,  92,   124,  132,  196,  201,  285, 

394,  443 
Pasteur,  83,  176 
Paton,  116 
Pavy,  90,  166,  189,  212,  216,  246,  257, 

261,  264,  267,  283 
Pearse,  337 
Pelouze,  108 
Perls,  141,  358,  435 
Petit,  3]  6,  323 
Petroff,  445 
Phillipeaux,  254 
Piotrowsky,  102 
Piorry,  286 
Ploucquet,  315 
Pohl,  145 
Ponfick, 157 
Poniklo,  263 
Popp,  523 

Posner,  141,  200,  358 
Power,  201 
Preusse,  48 
Priestley,  344 
Prout,  46,  95,   110,   117,  213,  253,  254, 

261,  264,  271,  335,  344 

QUECKETT,  565 
Quevenne,  344 
C^uincke,  259 
Quinquerez,  567 

RALFE,  117,  212,  236,  238,  242 
Eanke,  92 
Payer,  74,  155,  239,  245,  382,  445,  455, 

493,  505,  515,  541,  562,  591 
Kayney,  101,  296 
Kees,  84,  102,  436 
Regnauld,  373 
Eeinhardt,  363,  408 
Reliquet,  75 
Eenaud,  528,  604 
Eibbert,  141,  200 


INDEX    OF    AUTHORS. 


627 


Richardson,  246,  '266,  430,  43:.,  447 

Richter,  435 

Riegel,  55,  389 

Eilliet,  544 

Riolan,  591 

Kilchie,  163,  597 

Ritter,  436 

Roberts,  L.,  528 

Robin,  515 

Robinson,  203,  858 

Rohmann,  40 

Rollet,  591 

Eooke,  196 

Rosenstein,  275,  361,  374,  55o 

Rosenbucli,  160 

Ross,  257 

Rossman,  176 

Eoux,  168 

Runeberg,  203 

Eupstein,  259 

Eiissell,  75,  128 

Eiiysch,  587 

OALKOWSKI,  47,  117 

O     Salomon,  259 

Sanders,  259 

Saundby, 160, 196,  269 

Scanzoni,  374 

Schei-er,  40,  95,  109,  112,  118 

Schiflf,  237,  265,  268 

Schmidt,  C,  40o 

Schmidt,  126,  266 

achmidt-Mnlheim,  186 

Schmitz,  245,  260 

Schneider,  584 

Schottin,  417,  435 

Schultz,  175 

Schunck,  43,  46,  101,  143,  204 

Seegen,  210,  245 

Seidel,  240 

Sellers,  77 

Semraola,  202 

Senator,  47,  201,408,427 

Sharkey,  515 

Shearman,  111 

Sibson,  418 

Siebold,  560,  581 

Siegmund,  843 

Siemssen,  275 

Silver,  263 

Simmons,  228 

Simon,  402 

Simpson,  371,  485 

Sloane,  286 

Smith,  45 

Southam,  801,  384 

Southey,  168,  445 

Sparks,  201,  442 

Spiegelberg,  573 

Stanelmauer,  259 

Stadeler,  113 


Sludfoldt,  480 

Starr,  259 

Stein,  122 

Stewart,  378 

Stiller,  592 

Stocks,  168,  336 
I  Stockvis,  167,  201,  261 

Stoeber,  256 
j  Strange,  282 

Strecker,  113 

Stromeycr,  1 1 1 

Sutton,  401,  426 


rPANEET,  189 


Tapret.  547 
Tardieu,  261 
Taylor,  112,  260,  263 
Teissier,  117 
Tenneson,  75 
Tescbemacher,  200 
Thoma,  400,  427 

Thompson,  Sir  Henry,  56,  309,  004 
Thompson,  497 
Thorn,  512 
Thudichum,  101,  343 
Todd,  450,  462 
Toel,  110 

Tomowilz,  116,  567 
Tollens,  259 
Traube,  369,  425 
Trappa,  50 
Treitz,  419,  435 
Trommer,  208 

Trousseau,  226,  229,  289,  241 
Turner,  143 

TTNGER,  111 
1  L)      Uytierhoeven,  806 

VALENTINER,  123 

Y      Valleix,  523 
Vans  Arsdale,  871 
Velpeau,  478 
Vigia,  569 

Virchow,  453,  474,  502,  542,  546,  58d 
Vogel,  44,  48,  50,  77,  116,  157 
Voit,  126 
Vulpian,  254 

WAGNER,   196,   197,   384,  389,  433, 
543,  585 
Wagstafl'e,  806 
Waters,  336 
Watts,  224 
Waishe,  523 
Weir  Mitchell,  256 
Weissgerber,  141,  358 
Welcker,  176 
Wells,  382,  445,  516 
West,  128 


INDEX    OF    AUTHORS. 


"Whipham,  506 

Whitehead,  539 

Wieger,  374 

Wilde,  256 

Wilks,  26Q,  264,  397,  604 

Williams,  540 

Wilkinson,  445 

Willis,  131,  224,  228,435 

Wilson,  515 

Wittich,  von,  200 


Wohler,  80,  102,  111 
Wollaston,  106,  316 
Wood,  604 
Worm  Miiller,  228 

ZALESKY;  435 
Zeller,  45 
Zenker,  585 
Zinkeisen,  567 
Ziilzer,  116 


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THE  AMERICAN  JOURNAL  of  the  AHEDiCAL  SCIENCES, 

Edited  by  I.  MINIS  HAYS,  A.  M.,  M.  D., 

Is  published  Quarterly,  on  tlie  first  days  of  January,  April,  July 

and  October,  each  j^umber  containing-  over  Three  Hundred 

Octavo  Pag-es,  fully  Illustrated. 

In  his  contribution  to  "A  Century  of  American  Medicine,"  published  in  1876,  Dr. 
John  S.  Billings,  U.  S.  A.,  Librarian  of  the  National  Medical  Library,  Washington,  thus 
graphically  outlines  the  character  and  services  of  The  American  Journal — "The 
ninety-seven  volumes  of  this  Journal  need  no  eulogy.  They  contain  many  original  papers 
of  the  highest  value ;  nearly  all  the  real  criticisms  and  reviews  which  we  possess ;  and 
such  carefully  prepared  summaries  of  the  progress  of  medical  science,  and  abstracts  and 
notices  of  foreign  works,  that  from  this  file  alone,  were  all  other  productions  of  the  press 
for  the  last  fifty  years  destroyed,  it  would  be  possible  to  reproduce  the  great  majority  of 
the  real  contributions  of  the  world  to  medical  science  during  that  period." 

This  opinion  of  a  man  pre-eminently  qualified  to  judge  is  corroborated  by  the  great 
circle  of  readers  of  the  Journal,  which  includes  the  thinkers  of  the  profession  in  all  parts 
of  the  world.  During  the  coming  year  the  features  of  the  Journal  which  have  given 
unalloyed  satisfaction  to  two  generations  of  medical  men,  will  be  maintained  in  their 
vigorous  maturity. 

The  Original  Department  will  consist  of  elaborate  and  richly  illustrated  articles 
from  the  pens  of  the  most  eminent  members  of  the  profession  in  all  parts  of  the  country 
and  England. 

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and  impartiality,  and  will  contain  elaborate  reviews  of  new  works  and  topics  of  the  day, 
and  numerous  analytical  and  bibliographical  notices  by  competent  writers. 

Following  these  comes  the  Qiiarterly  Summary  of  Iraprovements  and  Dis- 
coveries in  the  Medical  Sciences,  which,  being  a  classified  and  arranged  condensation 
of  important  articles  appearing  in  the  chief  medical  journals  of  the  world,  furnishes  a 
compact  digest  of  naedical  progress  abroad  and  at  home. 

The  subscription  price  of  The  American  Jouenai.  op  the  Medical  Sciences  has 
never  been  raised  during  its  long  career.  It  is  still  sent  free  of  postage  for  Five  Dollars 
per  annum  in  advance. 

Taken  together,  the  Journal  and  News  combine  the  advantages  of  the  elaborate  prep- 
aration that  can  be  devoted  to  a  quarterly  with  the  prompt  conveyance  of  intelligence 
by  the  weekly ;  while,  by  special  management,  duplication  of  matter  is  rendered  im- 
possible. 

It  will  thus  be  seen  that  for  the  very  moderate  sum  of  NINE  DOLLAES  in  advance 
the  subscriber  will  receive  free  of  postage  a  weekly  and  a  quarterly  journal,  both  reflecting 
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octavo  pages,  stored  with  the  choicest  material,  original  and  selected,  that  can  be  furnished 
by  the  best  medical  minds  of  both  hemispheres.  It  would  be  impossible  to  find  elsewhere 
so  large  an  amount  of  matter  of  the  same  value  offered  at  so  low  a  price. 


Lea  Brothers  &  Co.'s  Publications — Period.,  Compends,  Manuals.    3 


The  safest  mode  of  remittance  1$  by  bank  -check  or  postal  money  order,  drawn  to 
the  order  of  the  undersigned ;  where  these  are  not  accessible,  remittances  for  subscrip- 
tions  may  be  made  at  the  risk  of  the  publishers  by  forwarding  in  rerjiniered  letters.  Address, 
Lea  Brotiieks  &  Co.,  Nos.  706  and  708  Sansom  St.,  Philadelphia. 


*  ^  *  Communications  to  both-  these  periodicals  are  invited  from  gentlemen  in  all  parts 
of  the  country.  Original  articles  contributed  exclusively  to  either  periodical  are  liberally 
paid  for  upon  publication.  When  necessary  to  elucidate  the  text,  illustrations  will  be  fur- 
nished without  cost  to  the  author. 

All  letters  pertaining  to  the  Editorial  Department  of  The  Medical  News  and  The 
American  Journal  of  the  Medical  Sciences  should  be  addressed  to  the  Editorial 
Offices,  1004  Walnut  S.treet,  Philadelphia. 

All  letters  pertaining  to  the  Business  Department  of  these  journals  should  be  addressed 
exclusively  to  Lea  Brothers  &  Co.,  706  and  708  Sansom  Street,  Philadelphia. 


HABTSJBLOIINE,  MBNItY,  A,  M.,  M.  D,, 

Latoly  Professor  of  Hycjiene  in  Vie  Vniversity  of  Pennsylvania. 

A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  edition,  thoroughly  revised  and  greatly  improved.  In  one  large  royal  12mo. 
volume  of  1028  pages,  with  477  illustrations.     Cloth,  |4.25 ;  leather  $5.00. 

industry  and  energy  of  its  able  editor. — Boston 
Medical  and  Surgical  Journal,  Sept.  3,  1874. 

We  can  say,  with  the  strictest  truth,  that  it  is'th© 
best  work  of  the  kind  with  which  we  are  acquaint- 
ed. It  embodies  in  a  condensed  form  all  recent 
contributions  to  practical  medicine,  and  is  there- 
fore useful  to  every  busy  practitioner  throughout 
our  country,  besides  being  admirably  adapted  to 
the  use  of  students  of  medicine.  The  book  i3 
faithfully  and  ably  executed. — Charleston  Medical 
Journal.  April,  1875. 


The  object  of  this  manual  is  to  afford  a  conven 
lent  work  of  reference  to  students  during  the  brief 
moments  at  their  command  while  in  attendance 
upon  medical  lectures.  It  is  a  favorable  sign  that 
it  has  been  found  necessary,  in  a  short  space  of 
time,  to  issue  a  new  and  carefully  revised  edition. 
The  illustrations  are  very  numerous  and  unusu- 
ally clear,  and  each  part  seems  to  have  received 
its  due  share  of  fittention.  We  can  conceive  such 
a  work  to  be  useful,  not  only  to  students,  but  to 
practitioners  as  well.    It  reflects  credit  upon  the 


STVJDBWTS'  SBBIJES  OF  3lAIfUALS, 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine 
and  Surgery,  written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size 
12mo.  volumes  of  300-540  pages,  richly  illustrated  and  at  a  low  price.  The  following  vol- 
umes are  now  ready:  Gould's  Surgical  Diagnosis,  Eobertson's  Physiological  Physics, 
Bruce's  Materia  Medica  and  Therapeutics,  Power's  Human  Physiology,  Clarke  and 
Lockwood's  Dissectors'  Manual,  Ralfe's  Clinical  Chemistry,  Treves'  Surgical  Applied 
Anatomy,  'P'EFFS'r's  Surgical  Pathology,  and  Klein's  ^/ewiente  of  Histology.  The  folloAving 
are  in  press :  Bellajiy's  Operative  Surgery,  Bell's  Comparative  Physiology  and  Anatomy, 
(shortly),  Pepper's  Forensic  Medicine,  and  Curnow's  Medical  Applied  Anatomy.  For 
separate  notices  see  index  on  last  page. 

SBBIBS  OF  CLINICAL  MAWUALS. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the 
profession  with  a  collection  of  authoritative  monographs  on  important  clinical  subjects 
in  a  cheap  and  portable  form.  The  volumes  will  contain  about  650  pages  and  will  be 
freely  illustrated  by  chromo-lithographs  and  woodcuts.  The  following  volumes  are 
just  ready:  Treves  on  Intestinal  Obstruction;  and  Savage  on  Insanity  and  Allied  Neu- 
roses; The  following  are  in  active  preparation:  Hutchinson  on  SyjMlis;  Bryant 
on  the  Breast;  Morris  on  Surgical  Diseases  of  the  Kidney;  Broadbent  on  the  Pulse; 
BuTLiN  on  the  Tongue  (shortly);  Owen  on  Surgical  Diseases  of  Children;  Lucas  on 
Diseases  of  the  Urethra;  Marsh  on  Diseases  of  the  Joints, 'Pics,  on  Fractures  and  Disloca- 
tions, and  Ball  on  the  Rectum  and  Anus.     For  separate  notices  see  index  on  last  page. 

NBILL,  JOHN,  M,  D.,   and  SMITH,  F.  G.,  M.  D., 

Late  Surgeon  to  the  Penna.  Hospital.  Prof,  of  the  Institutes  of  3Icd.  in  the  Vniv.  of  Penna. 

An  Analytical  Compendium  of  the  Various  Branches  of  Medical 
Science,  for  the  use  and  examination  of  Students.  A  new  edition,-  revised  and  improved. 
In  onelarge  royal  12mo.  volume  of  974  pages,  with  374  woodcuts.    Cloth,  §4;  leather,  $4.75. 


LUDLOW,  J.L.,3LD., 

Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 

A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics.  To  which 
is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised,  and  greatly  extended 
and  enlarged.  In  one  handsome  royal  12mo.  volume  of  816  large  pages,  with  870  illus- 
trations.    Cloth,  $3.25 ;  leather,  $3.75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


Lea  Brothers  &  Co.'s  Publications — Dictionaries. 


Late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia, 

MEDICAL  LEXICOE" ;  A  Dictionary  of  Medical  Science :  Containing 
a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pliarmacology,  Pharmacj',  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulse  for  Officinal, 
Empirical  and  Dietetic  Preparations,  witli  the  Accentuation  and  Etymology  of  the  Terms, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lex,icon.  Edited  by  Kichard  J.  Dungmson,  M.  D.  In  one  very  large  and 
handsome  royal  octavo  volume  oi  1139  pages.  Cloth,  $6.50 ;  leather,  raised  bands,  $7.50 ; 
very  handsome  half  Eussia,  raised  bands,  $8. 

The  object  of  the  author,  from  the  outset,  has  not  been  to  make  the  work  a  mere  lexi- 
con or  dictionary  of  terms,  but  to  afford  under  each  word  a  condensed  view  of  its  various 
medical  relations,  and  thus  to  render  the  work  an  epitome  of  the_  existing  condition  of 
medical  science.  Starting  with  this  view,  the  immense  demand  which  has  existed  for  the 
work  has  enabled  him,  in  repeated  revisions,  to  augment  its  completeness  and  usefulness, 
until  at  length  it  has  attained  the  position  of  a  recognized  and  standard  authority  wherever 
the  language  is  spoken.  Special  pains  have  been  taken  in  the  preparation  of  the  present 
edition  to  maintain  this  enviable  reputation.  The  additions  to  the  vocabulary  are  more 
numerous  than  in  any  previous  revision,  and  particular  attention  has  been  bestowed  on  the 
accentuation,  Avhich  will  be  found  marked  on  every  word.  The  typographical  arrangement 
has  been  greatly  improved,  rendering  reference  mucli  more  easy,  and  every  care  has  been 
taken  with  the  mechanical  execution.  The  volume  now  contains  the  matter  of  at  least 
four  ordinary  octavos. 


A  book  of  which  every  American  ought  to  be 
proud.  When  the  learned  author  of  the  work 
passed  away,  probably  al  1  of  us  feared  lest  the  book 
should  not  maintain  its  place  in  the  advancing 
science  whose  terms  it  defines.  Fortunately,  Dr. 
Richard  J.  Dunglison,  having  assisted  his  father  in 
the  revision  of  several  editions  of  the  work,  and 
having  been,  therefore,  trained  in  the  methods 
and  imbued  with  the  spirit  of  the  book,  has  been 
able  to  edit  it  as  a  work  of  the  kind  should  be 
edited — to  carry  it  on  steadily,  without  jar  or  inter- 
ruption, along  the  grooves  of  thought  it  has  trav- 
elled during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and 
carried  through,  it  is  only  necessary  to  state  that 
Enore  than  six  thousand  new  subjects  have  been 
added  in  the  present  edition. — Philadelphia  Medical 
Tittles,  Jan.  3, 1874. 

About  the  first  book  purchased  by  the  medical 
student  is  the  Medical  Dictionary.  The  lexicon 
explanatory  of  technical  terms  is  simply  a  sine  qua 
non.  In  a  science  so  extensive  and  with  such  col- 
laterals as  medicine,  it  is  as  much  a  necessity  also 
to  the  practising  physician.  To  meet  the  wants  of 
students  and  most  physicians  the  dictionary  must 
be  condensed  while  comprehensive,  and  practical 
while  perspicacious.  It  was  because  Dunglison's 
met  these  mdications  that  it  became  at  once  the 
dictionary  of  general  use  wherever  medicine  was 
studied  in  the  English  language.  In  no  former 
revision  have  the  alterations  and  additions  been 
so  great.  The  chief  terms  have  been  set  in  black 
tetter,  while  the  derivatives  follow  in  small  caps; 
an  arrangement  which  greatly  facilitates  reference. 
— Cincinnati  Lancet  and  Clinic,  Jan.  10, 1874. 

As  a  standard  work  of  reference  Dunglison's 


work  has  been  well  known  for  about  forty  years, 
and  needs  no  words  of  praise  on  our  part  to  recom- 
mend it  to  the  members  of  the  medical,  and  like- 
wise of  the  pharmaceutical,  profession.  The  latter 
especially  are  in  need  of  a  work  which  gives  ready 
and  reliable  information  on  thousands  of  subjects 
and  terms  which  they  are  liable  to  encounter  in 
pursuing  their  daily  vocations,  but  with  which  they 
cannot  be  expected  to  be  familiar.  The  work 
before  us  fully  supplies  this  want. — Attierican  Jour- 
nal of  Pharmacy,  Feb.  1874. 

Particular  care  has  been  devoted  to  derivation 
and  accentuation  of  terms.  With  regard  to  the 
latter,  indeed,  the  present  edition  may  be  consid- 
ered a  complete  "Pronouncing  Dictionary  of 
Medical  Science."  It  is  perhaps  the  most  reliable 
work  published  for  the  busy  practitioner,  as  it  con- 
tains information  upon  every  medical  subject,  in 
a  form  for  ready  access,  and  with  a  brevity  as  ad- 
mirable as  it  is  practical. — Southern  Medical  Record, 
Feb.  1874. 

A  valuable  dictionary  of  the  terms  employed  in 
medicine  and  the  allied  sciences,  and  of  the  rela- 
tions of  the  subjects  treated  under  each  head.  It 
well  deserves  the  authority  and  popularity  it  has 
ohi&ined.— British  Med.  Jour.,  Oct.  31, 1874. 

Few  works  of  this  class  exhibit  a  grander  monu- 
ment of  patient  research  and  of  scientiiic  lore. — 
London  Lancet,  Blay  13,  1875. 

Dunglison's  Dictionary  is  incalculably  valuable, 
and  indispensable  to  every  practitioner  of  medi- 
cine, pharmacist  and  dentist. —  Western  Lancet, 
March,  1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Gazette. 


MOBLYWj  MICSAMD  !>.,  W.  D. 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  Collateral 

Sciences.  Eevised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of  520 
double-columned  images.     Cloth,  $1.50;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table. — Southern 
Medical  and  Surgical  Journal.  

MOJDWELL,  G.  F.,  F.  B.  A.  S.,  F.  C,  S., 

Lecturer  on  Natural  Science  at  Clifton  College,  England. 

A  Dictionary  of  Science :  Comprising  Astronomy,  Chemistry,  Dynamics,  Elec- 
tricity, Heat,  Hydrodynamics,  Hydrostatics,  Light,  JSIagnetism,  Mechanics,  Meteorology, 
Pneumatics,  Sound  and  Statics.  Contributed  by  J.  T.  Bottomley,  M.  A.,  F.  C.  S.,  William 
Crookes,  F.R.S.,  F.C.S.,  Frederick  Guthrie,  B.A.,  Ph.  D.,  R.  A.  Proctor,  B.A.,  F.E.A.S., 
«a.  F.  Eodwell,  Editor,  Charles  Tomlinson,  F.R.S.,  F.C.S.,  and  Eichard  Wornell,  M.A., 
B.Sc.  Preceded  by  an  Essay  on  tlie  History  of  the  Pliysical  Sciences.  In  one  handsome 
octavo  volume  of  702  pages,  with  143  illustrations.     Clotli,  $5.00. 


Lea  Brotiikrs  &  Co.'s  Publicationh — Anatomy.  5 

GRAY,  JIBNRY,  F,  B.  S., 

Lecturer  on  Anato'iny  at  St.  Ocor</o's  HnapltaL,  London. 

Anatomy,  Descriptive  and  Surgical.  The  Drawings  by  II.  V.  Cahteb,  M.  D., 
and  Dr.  Wkstmaoott.  Tlic  dissections  jointly  by  the  Autiioji  and  Dr.  Cartkr.  With 
an  Introduction  on  CJcneral  Anatomy  iuid  Dovolo[itnent  hy  T,  IIolmkh,  M.  A.,  Surgeon  to 
St.  George's  Hospital.  Edited  by  T.  Pickering  rick,  V.  K.  C.  B.,  Surgeon  to  and  Jvectiirer 
on  Anatomy  at  St.  (leorge's  llospitid,  Lonchm,  l-'.xaminer  in  Anatoiny,_Iloyal  College  of 
Surgeons  ol'  England.  A  new  American  from  the  tentli  enlarged  and  inif)roved  London 
edition.  To  which  is  added  the  second  American  from  the  latest  English  edition  ot 
Landmarks,  Medical  and  Sukoujal,  by  Lutiijok  JToldjjn,  F.I!,. U.S.,  author  of 
"Human  Osteology,"  "A  Manual  of  Dissections,"  etc.  In  one  imperial  octavo  volume 
of  1023  Images,  wi til  5G4  large  and  elaborate  engravings  on  M'ood.  Cloth,  $0.00  ;  leather, 
$7.00 ;  very  handsome  half  Russia,  raised  bands,  1)7.50. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  tlie  details  necessary  for  the  student,  but  also  the  siijjjlication  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  fortlie 
learner  and  an  admirable  woric  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  tlie  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  jjrinted  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  They  thus  form  a  complete  and 
splendid  series,  which  will  greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy, 
and  will  also  serve  to  refresh  the  memory  of  those  who  may  find  in  the  exigencies  of 
practice  the  necessity  of  recalling  the  details  of  the  dissecting-room.  Combining,  as  it 
does,  a  complete  Atlas  of  Anatomy  with  a  thorough  treatise  on  systematic,  descriptive 
and  applied  Anatomy,  the  work  will  be  found  of  greafservice  to  all  physicians  who  receive 
students  in  their  offices,  relieving  both  jjreceptor  and  pupil  of  much  labor  in  laying  the 
_groundwork  of  a  thorough  medical  education. 

Landynarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  whicii  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  fui-nish  all  the  assistance  that  can  be  rendered  by 
type  and  illustration  in  anatomical  study. 

There  is  probably  no  work  used  so  universally 

by  phj'sicians  and  medical  students  as  this  one. 
It  is  deserving  of  the  confidence  that  tliey  repose 
in  it.  If  the  present  edition  is  compared  with  that 
issued  two  years  ago,  one  will  readily  see  how 
much  it  has  been  improved  in  that  time.  Many 
pages  have  been  added  to  the  text,  especially  in 
those  parts  that  treat  of  lustologj'  and  many  new 


This  well-known  work  comes  to  us  as  the  latest 
American  from  the  tenth  English  edition.    As  its 
title  indicates,  it  has  passed  tlirough  many  hands 
and  has  received  many  additions  and  revisions. 
The  work  is  not  susceptible  of  more  improvement. 
Taking  it  all  in  all,  its  size,  manner  of  make-up, 
its  character  and  illustrations,  its  general  accur- 
acy of  description,  its  practical  aim,  and  its  per-  i  i.m/00  ij^m^o  vncv  1.1  cuu  ^1  ijic^w.^f^j,  «u^  ^..c^..,  ^^„ 
spicuity  of  style,  it  is  the  Anatomy  best  adapted  to    cuts  have  been  introduced  and  old  ones  modified, 
the  waiits  of  the  student  and  practitioner. — Medical   ^ — Journal  of  the  American  Medical  Association,  Sept. 
Becord,  SejH.  15, 1883.  I  1,  1883. 


Also  for  sale  separate — 
IlOZnB]S\  ZUTMJEB,  F,  M,  C.  S,, 

Surgeon  to  St.  Bartholomew'' s  and  the  Foundling  Hospitah,  London. 
Landmarks,  Medical  and  Surgical.     Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy  in 
the  Pennsylvania  Academy  of  the  Fine  Arts,  formerly  Lecturer  on  Anatomy  in  the  Phila- 
delphia School  of  Anatomy.     In  one  handsome  12mo.  volume  of  148  pages.     Cloth,  $1.00. 


This  little  book  is  all  that  can  be  desired  within 
its  scope,  and  its  contents  will  be  found  simply  in- 
valuable to  the  young  surgeon  or  physician,  since 
they  bring  before  him  such  data  as  he  requires  at 
every  examination  of  a  patient.  It  is  written  in 
language  so  clear  and  concise   that   one    ought 


almost  to  learn  it  by  heart.  It  teaches  diagnosis  by 
external  examination,  ocular  and  palpable,  of  the 
body,  with  such  anatomical  and  physiological  facts 
as  directly  bear  on  the  subject.  It  is  eminently 
tlie  student's  and  young  practitioner's  book. — Phy- 
sician and  Surgeon,  Kov.  ISSl. 


JVILSOW,  FBAS31US,  F,  Mo  S,  ,^ 

A  System  of  Human  Anatomy,  General  and  Spec^  Edited  by  "\V.  H. 
GoBRECHT,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of 
Ohio.  In  one  large  and  handsome  octavo  volume  of  616  pages,  with  397  illustrations. 
Cloth,  $4.00 ;  leather,  $5.00.  

SMITH,  S,  H.,  M,  !>.,  and  SOBJSFR,  WM,  F.,M.D,, 

Emeritus  Prof,  of  Surgery  in  the  Univ.  of  Penna.,  etc.         Late  Prof,  of  Anaf.  in  the  Univ.  of  Penna. 
An  Anatomical  Atlas,  Illustrative  of  the  Structure  of  the  Human  Body.     In  one 
large  imperial  octavo  volume  of  200  pages,  with  634  beautiful  figures.      Cloth,  $4.50. 

CLELAWD,  JOMW,  IL  J>.,  JP.  M.  S., 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Gaiway. 

A  Directory  for  the  Dissection  of  the  Human  Body.  In  one  12mo. 
volume  of  178  i)ages.     Cloth,  $l.'2o. 


6  Lea  Brothers  &  Co.'s  Publications — Anatomy, 

ALLBW,  SABBISOJy,  M.  D,, 

Professor  of  Physiology  in  the  University  of  Pennsylvania. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Siirgical 
Relations,  For  the  use  of  Practitioners  and  Students  of  Medicine.  With  an  Intro- 
ductory Section  on  Histology.  By  E.  O.  Shakespeare,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  sis  Sections,  each  in  a  portfolio.  Section  I.  Histology. 
Section  II.  Bones  and  Joints.  Section  III.  Muscles  and  Fasci-e.  Section  IV. 
Arteries,  Veins  and  Lymphatics.  Section  V.  Nervotjs  System.  Section  VI. 
Organs  of  Sense,  of  Digestion  and  Genito-Urinary  Organs,  Embryology, 
Development,  Teratology,  Superficial  Anatomy,  Post-Mortem  Examinations, 
AND  General  and  Clinical  Indexes.  Just  ready.  Price  per  Section,  each  in  a  handsome 
portfolio,  $3.50;  also  bound  in  one  volume,  cloth  $23.00;  very  handsome  half  Eussia, 
raised  bands  and  open  back,  $25.00.    For  sale  by  suhscri'ptlon  only.    Apply  to  the  Fublishers. 

Extract   from   Introduction. 

It  is  the  design  of  this  book  to  present  the  facts  of  human  anatomy  in  the  manner  best 
suited  to  the  requirements  of  the  student  and  the  practitioner  of  medicine.  The  author 
believes  that  such  a  book  is  needed,  inasmuch  as  no  treatise,  as  far  as  he  knows,  contains,  in 
addition  to  the  text  descriptive  of  the  subject,  a  systematic  presentation  of  such  anatomical 
facts  as  can  be  applied  to  practice. 

A  book  which  will  be  at  once  accurate  in  statement  and  concise  in  terms ;  which  will  be 
an  acceptable  expression  of  the  present  state  of  the  science  of  anatomy ;  which  will  exclude 
nothing  that  can  be  made  applicable  to  the  medical  art,  and  which  will  thus  embrace  all 
of  surgical  importance,  while  omitting  nothing  of  value  to  clinical  medicine, — ^would  appear 
to  have  an  excuse  for  existence  in  a  country  where  most  surgeons  are  general  practitioners, 
and  where  there  are  few  general  practitioners  who  have  no  interest  in  surgery. 


It  is  to  be  considered  a  study  of  applied  anatomy 
in  its  widest  sense — a  sj^stematic  presentation  of 
such  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgery.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 
sidered a  dry  subject.  The  department  of  Histol- 
ogy is  treated  in  a  masterly  manner,  and  the 
ground  is  travelled  over  by  one  thoroughly  famil- 
iar with  it.    The  illustrations  are  made  witti  great 


care,  and  are  simply  superb.  There  is  as  much 
of  practical  application  of  anatomical  points  to 
the  every-day  wants  of  the  medical  clinician  as 
to  those  of  the  operating  surgeon.  In  fact,  few 
general  practitioners  will  read  the  work  without  a 
feeling  of  surprised  gratification  that  so  many 
points,  concerning  which  they  may  never  have 
thought  before  are  so  well  presented  for  their  con- 
sideration. It  is  a  worlv  which  is  destined  to  be 
the  best  of  its  kind  in  any  language. — Medical 
Record,  Nov.  25, 1882. 


CLAMKE,  W.  B.,  F.M.  C.S.  <&  LOCKWOOD, C.  B.>  F.B. C.S. 

Demonstrators  of  Anatomy  at  St.  Bartholomew'' s  Hospital  Medical  School.  London. 
The  Dissector's  Manual.     In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49   illustrations.     Limp   cloth,   red  edges,   $1.50.      Just  ready.     See  Students'  Series  of 
Manuals,  page  3. 


This  is  a  very  excellent  manual  for  the  use  of  the 
student  who  desires  to  learn  anatomy.  The  meth- 
ods of  demonstration  seem  to  us  very  satisfactory. 
There  are  many  woodcuts  which,  for  the  most 


part,  are  good  and  instructive.  The  book  is  neat 
and  convenient.  We  are  glad  to  recommend  it. — 
Boston  Medical  and  Surgical  Journal,  Jan.  17, 1884. 


TBBVMS,  FBBJDBBICK,  B.  B.  C.  S., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital. 
Surgical  Applied  Anatomy.     In  one  pocket-size  12mo.  volume  of  540  pages, 
with  61  illustrations.   Limp  cloth,  red  edges,  $2.00.     Just  ready.     See  Student^  Series  oj 
Manuals,  page  3. 


He  has  produced  a  work  which  will  command  a 
larger  circle  of  readers  than  the  class  for  which  it 
was  written.  This  union  of  a  thorough,  practical 
acquaintance  with  these  fundamental  branches, 


quickened  by  daily  use  as  a  teacher  and  practi- 
tioner, has  enabled  our  author  to  prepare  a  work 
which  it  would  be  a  most  difficult  task  to  excel. — 
The  American  Practitioner  Feb.  1884. 


cvBWow,  jQiaJsr,  m.  d.,  b.  b.  a  r., 

Professor  of  Anat0by  at  King^s  College,  Physician  at  King's  College  Hospital. 
Medical  Applied  Anatomy.     In  one  pocket-size   12mo.  volume.     Preparing, 
See  Students'  Series  of  Manuals,  page  3. 

BBLLAMT,  BBWABB,  B.  B.  C.  S., 

Senior  Assistant-Surgeon  to  the  Charing-Cross  Hospital,  London. 

The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  Important  Surgical  Regions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
operative  Surgery.    In  one  12mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2.25. 


HARTSHORNE'S  HANDBOOK  OF  ANATOMY 
AND  PHYSIOLOGY.  Second  edition,  revised. 
In  one  royal  12mo.  volume  of  310  pages,  with  220 
woodcuts.    Cloth,  $1.75. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  two  octavo  volumes  of  1007  pages, 
with  320  woodcuts.    Cloth,  S6.00. 


Lea  Brothers  &  Co.'s  Publications — Anat.,  Physics,  Physiol,        7 
I) ALTON,  JOILJSr  a,  M.  7)., 

Professor  Emeritus  of  Physiology  in  the  CoUcje  of  Physicians  and  Surgeons,  New  York. 

The  Topographical  Anatomy  of  tho  Brain.  In  tJiree  very  handsome  quarto 
volumes  comprisin<,'  178  pages  of  descriptive  text.  liluHtrated  with  48  full  paL'e  photo- 
graphic pliites  of  Brnln  Sections,  witli  a  like  number  of  explanatory  plates,  as  well  as  many 
woodcuts  through  the  text.  Price  for  the  complete  work,  $30.  Jmt  ready.  For  Hoh  by 
subscription.  As  but  few  of  the  copies  reserved  for  this  country  now  remain  unsold, 
gentlemen  desiring  the  work  will  do  well  to  apply  to  the  publishers  at  an  early  date. 

preci.so  and  accurato,  and  tho  methods  by  which 
tlio  sectionw  were  made  and  the  Hfieeimens  re- 
prodiioed  arc  given  very  plainly  iu  an  introductory 
chapter,  wliiofi  cannot  fail  to  Vjo  of  the  greatest 
value  to  any  one  desirou.s  of  making  similar  prep- 


This  is  one  of  tho  most  magnificent  works  on 
anatomy  that  lias  api)f'ared  during  the  present 
generation,  and  will  iiol  only  .snporKode  all  its 
predecessors  on  the  topograijIiicHl  luiatorny  of  the 
brain,  but  make  any  further  work  on  the  same 
lines  unnecessary.      It   contains   forty-eight  ex-  {  arations.     'Criticism   on  such  a    work  is  supe'r 


quisito  illustrations  of  the  brain  en  viam^c  and  in 
sections.  Not  only  has  perfect  accuracy  been 
secured,  but  one  of  the  finest  and  most  artistic 
works  of  recent  times  lias  been  jiresented  to  the 
medical  public.  Its  value  as  a  work  of  reference 
is  considerably  increased  Ijy  the  very  careful  out- 
line sketches  which  accompany  the  plates  and 
which  enable  them  to  be  easily  followed  and 
understooil.  These  sketches  are  very  complete 
and  accurate,  and  have  been  reproduced  from 
tracings.  The  descriptions  by  tlie  author  are  clear, 


fluous.  We  can  only  congratulate  Dr.  Dalton,  his 
assistants,  and  the  publishers  on  the  energy  they 
liave  shown  iu  undertaking  such  a  work,  and  tlie 
success  with  wiiio?i  they  have  overcome  a  task 
presenting  so  many  mechanical  difficulties.  We 
envy  our  American  confreres  the  authorship  and 
execution  of  so  beautiful  and  useful  an  addition 
to  medical  literature.  Much  light  is  thrown 
on  some  obscure  relations  of  parts  of  the  brain 
which  have  never  before  been  seen  in  correct 
juxtaposition.— iondoft  Lancet,  April  18, 1885. 


BY  THE   SAME  AUTHOR. 
Doctrines  of  the  Circulation  of  the  Blood.     A  History  of  Physiological 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.     In  one  handsome 
12mo.  volume  of  293  pages.     Cloth,  $2.     Just  ready. 

In  the  progress  of  physiological  study  no  fact  I  of  three  or  four  which  have  been  written  within  a 
was  of  greater  moment,  none  more  completely  few  years  by  American  physicians.  It  is  in  several 
revolutionized  the  theories  of  teachers,  than  the  respects  the  most  complete.  The  volume,  though 
discovery  of  the  circulation  of  the  blood.  This  small  in  size,  is  one  of  the  most  croditable  con- 
explains  the  extraordinary  interest  it  has  to  all  tributionsfroman  American  pen  to  medical  history 
medical  historians.    The  volume  before  us  is  one  |  that  has  appeared. — Med.  d-  Surg.  Rep.,  Dec.  6, 1884. 

ELLIS,  GBOBGE  VINEU, 

Emeritus  Professor  of  Anatomy  in  TJniversity  College,  London. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  of  the 
Human  Body  by  Dissection.  From  the  eiglith  and  revised  London  edition.  In  one  very 
handsome  octavo  volume  of  716  pages,  witli  249  illustrations.    Cloth,  $4.25  •  leather,  $5.2o. 

JEtOBBBTS,  JOHN  B.,  A.  M.,  31.  J>., 

P)-of.  of  Applied  Anat.  and  Oper.  Surg,  in  Phila.  Polyclinic  and  Coll.  for  Graduates  in  Medicine. 
The  Compend.  of  Anatomy.     For  use  in  the  dissecting-room  and  in  preparing 
for  examinations.     In  one  16mo.  volume  of  196  pages.     Lim^D  cloth,  75  cents. 

DBAJPEM,  JOMN  C,  31.  D,,  LL.  D., 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 

Medical  Physics.  A  Text-book  for  Students  and  Practitioners  of  Medicine.  In 
one  octavo  volume  of  725  pages,  with  376  woodcuts,  mostly  original.  Cloth,  §4.  In  a  few  days: 

From  the  Preface. 

The  fact  that  a  knowledge  of  Physics  is  indispensable  to  a  thorough  understanding  of 
Medicine  has  not  been  as  fully  realized  in  this  country  as  in  Europe,  where  the  admirable 
works  of  Desplats  and  Gariel,  of  Robertson  and  of  numerous  German  writers  constitute  a 
branch  of  educational  literature  to  which  we  can  show  no  parallel.  A  full  appreciation 
of  this  the  author  trusts  will  be  sufficient  justification  for  i:)lacing  in  book  form  the  sub- 
stance of  his  lectures  on  this  department  of  science,  delivered  during  manv  rears  at  the 
University  of  the  City  of  Kew  York. 

Broadly  speaking,  this  work  aims  to  impart  a  knowledge  of  the  relations  existing 
between  Physics  and  Medicine  in  their  latest  state  of  development,  and  to  embody  in  the 
pursuit  of  this  object  whatever  experience  the  author  has  gained  during  a  long  period  of 
teaching  this  special  branch  of  applied  science. 

BOBBBTSON,  J.  3IcGMBGOB,  3L  A.,  IT.  B., 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgoic. 
Physiological  Physics.     In  one  12mo.  volume  of  537  pages,  with  219  illustra- 
tions.    Limp  cloth,  $2.00.     Just  ready.     See  Students'  Series  of  Jfanuals,  page  3. 

The  title  of  this  work  sufficiently  explains  the  '  ments.  It  will  be  found  of  great  value  to  the 
nature  of  its  contents.  It  is  designed  as  a  man-  ;  practitioner.  It  is  a  carefulh^  prepared  book  of 
ual  for  the  student  of  medicine,  an  auxiliary  to  ;  reference,  concise  and  accurate,  and  as  such  we 
histext-bookinphysiology,anditwouldbepartieu-  '  lieartily  recommend  it.— Journal  of  the  American 
larly  useful  as  a  guide  to  his  laboratory  experi-  ,  Medical  Association,  Dec.  6, 1884. 

BBLL,  F.  JBFFMBT,  31.  A., 

Pi-ofessor  of  Comparative  Anatomy  at  King's  College,  London. 

Comparative  Physiology  and  Anatomy.  Shortly.  See  Students'  Series  of 
3Tanuals,  page  3. 


8        Lea  Brothers  &  Co.'s  Publications — Physiolog-y,  Chemistry. 


DALTOJSr,  JOSW  C,  M.  D., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.  Seventh  edition,  thoroughly  revised  and  rewritten.  In  one 
very  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
15.00 ;  leather,  $6.00 ;  very  handsome  half  Eussia,  raised  bands,  |6.50. 


The  merits  of  Professor  Dalton's  text-book,  his 
smooth' and  pleasing  style,  the  remarkable  clear- 
ness of  his  descriptions,  which  leave  not  a  cliapter 
obscure,  his  cautious  judgment  and  the  general 
correctness  of  his  facts,  are  perfectly  known.  They 
have  made  his  text-book  the  one  most  familiar 
to  American  students. — Med.  Record,  March  4, 1882. 

Certainly  no  physiological  work  has  ever  issued 
from  the  press  that  presented  its  subject-matter  in 
a  clearer  and  more  attractive  light.  Almost  every 
page  bears  evidence  of  the  exhaustive  revision 
that  has  taken  place.    The  material  is  placed  in  a 


more  compact  form,  yet  its  delightful  charm  is  re- 
tained, and  no  subject  is  thrown  into  obscurity. 
Altogether  this  edition  is  far  in  advance  of  any 
previous  one,  and  will  tend  to  keep  the  profession 
posted  as  to  the  most  recent  additions  to  our 
physiological  knowledge. — Miehiqan  Medical  News, 
April,  1882. 

One  can  scarcely  open  a  college  catalogue  that 
does  not  have  mention  of  Dalton's  Physiology  as 
the  recommended  text  or  consultation-book.  For 
American  students  we  would  unreservedly  recom- 
mend Dr.  Dalton's  work.- Fa.  ilfed.  if  oni/ii^,July,'82. 


FOSTEB,  MICHAEL,  M.  D.,  F.  M,  S., 

Professor  of  Physiology  in  Cambridge  University,  England. 
Test-Book  of  Physiology.     Third  American  from  the  fourth  English  edition, 
with  notes  and  additions  by  E.  T.  Eeiohert,  M.  D.     In  one  handsome  royal  12mo.  volume 
of  over  1000  pages,  with  about  300  illustrations.  Cloth,  $3.25 ;  leather,  $3.75.   In  a  few  days. 
A  notice  of  the  previous  edition  is  appended. 


A  more  compact  and  scientific  work  on  physiol- 
ogy has  never  Deen  published,  and  we  believe  our- 
selves not  to  be  mistaken  in  asserting  that  it  has 
now  ueen  introduced  into  every  medical  college 
in  which  the  English  language  is  spoken.  This 
work  conforms  to  the  latest  researches  into  zoology 
and  comparative  anatomy,  and  takes  into  consid- 


eration the  late  discoveries  in  physiological  chem- 
istry and  the  experiments  in  localization  of  Ferrier 
and  others.  The  arrangement  followed  is  such  as 
to  render  the  whole  subject  lucid  and  well  con- 
nected in  its  various  parts. — Chicago  Medical  Jowc 
nal  and  Examiner,  August,  1882. 


FOWEM,  HENMY,  M,  B.,  F,  M.  C,  S., 

Examiner  in  Physiology,  Royal  College  of  Surgeons  of  Ejigland. 
Human  Physiology.      In  one  handsome  pocket-size  12mo.  volume  of  396  pages, 
with  47  illustrations.     Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  3. 


The  prominent  character  of  this  work  is  that  of 
judicious  condensation,  in  which  an  able  and  suc- 
cessful effort  appears  to  have  been  made  by  its 
accomplished  author  to  teach  the  greatest  number 
of  facts  in  the  lewest  possible  words.  The  result 
is  a  specimen  of  concentrated  intellectual  pabu- 
lum seldom  surpassed,  which  ought  to  be  care- 
fully ingested  and  digested  by  every  practitioner 
who  desires  to  keep  himself  well  informed  upon 
this  most  progressive  of  the  medical  sciences. 
The  volume  is  one  which  we  cordially  recommend 


to  every  one  of  our  readers. — The  American  Jour- 
nal of  the  Medical  Sciences,  October,  1884. 

This  little  work  is  deserving  of  the  nighest 
praise,  and  we  can  hardly  conceive  how  the  main 
facts  of  this  science  could  have  been  more  clearly 
or  concisely  stated.  The  price  of  the  work  is  such 
as  to  place  it  within  the  reach  of  all,  while  the  ex- 
cellence of  its  text  will  certainly  secure  for  it  most 
favorable  commendation  — Cincinnati  Lancet  and 
Clinic,  Feb.  16, 1884. 


CABJPFJSTTFB,  WM.  B.,  31.  D.,  F.  M.  S.,  F.  G.  S.,  F.  B.  S.^ 

Registrar  to  the  University  of  London,  etc. 

Principles  of  Human  Physiology.  Edited  by  Henry  Power,  M.  B.,  Lond., 
F.  R.  C.  S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.  A  new  American  from  the 
eighth  revised  and  enlarged  edition,  with  notes  and  additions  by  Francis  G.  Smith,  M.  D., 
late  Professor  of  the  Institutes  of  Medicine  in  the  University  of  Pennsylvania.  In  one 
very  large  and  liandsome  octavo  volume  of  1083  pages,  with  two  plates  and  373  illus- 
trations.   Cloth,  $5.50 ;  leather,  $6.50 ;  half  Eussia,  $7. 

FOWNES,  GEOMGE,  Fh.  J>. 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Re- 
vised by  Henry  Watts,  B.  A.,  F.  E.  S.  New  American  edition.  In  one  large  royal  12mo. 
volume  of  over  1000  pages,  with  200  illustrations  on  wood  and  a  colored  plate.  Cloth,. 
12.75 ;  leather,  $3.25.     In  press. 

A  notice  of  the  previous  edition  is  appended. 
The  book  opens  with  a  treatise  on  Chemical  of  late  years,  the  chapter  on  the  General  Principles 
Physics,  including  Heat,  Light,  Magnetism  and  of  Chemical  Philosophy  has  been  entirely  rewrit- 
Electricity.  These  subjects  are  treated  clearly  ten.  The  latest  views  on  Equivalents,  Quantiva- 
and  briefly,  but  enough  is  given  to  enable  the  stu-  lence,  etc.,  are  clearly  and  fully  set  forth.  This 
dent  to  comprehend  the  facts  and  laws  of  Chemis-  last  edition  is  a  great  improvement  upon  its  prede- 
try  proper.  It  is  the  fashion  of  late  years  to  omit  cessors,  which  is  saying  not  a  little  of  a  book  that 
these  topics  from  works  on  chemistry,  but  their  has  reached  its  twelfth  edition.— OAio  Medical  Re- 
omission  is  not  to  be  commended.  As  was  required  corder,  Oct.,  1878. 
by  the  great  advance  in  the  science  of  Chemistry 


Wohler's  Outlines  of  Organic  Chemistry.    Edited  by  Fittig.    Translated 
by  Ira  Remsen,  M.  D.,  Ph.  D.     In  one  12mo.  volume  of  550  pages.     Cloth,  $3. 

GALLOWAY'S  QUALITATIVE  ANALYSIS.    New  I  CARPENTER'SPRIZE  ESSAY  ONTHEUSEAND 
edition.  Abuse  of  Alcoholic  Liquors  in  Health  and  Dis- 

LEHMANN'S  MANUAL  OP  CHEMICAL  PHYS-        ease.  With  explanations  of  scientific  words.  Small 
lOLOGY.     In  one  octavo  volume  of  327  pages,        12mo,    178  pages.    Cloth,  60  cents. 
with  41  illustrations.    Cloth,  S2.25.  | 


9 


Lea  Brothers  &  Co.'s  Publications — CheraiHtry. 
FBANKLAND,  B.,  I),  6.X.,  Jb\  U.S.,  &JAPP,  Ph.  J>.,  F,  I.  C\, 


Assist.  I'm/,  iif  (;hi;rninlT 
School  of  Hciance, 


-y  in  the  Normal 
London. 


Profesnor  of  Chr.mistri/  in  the.  Normal  School 
of  Science,  Jjondon. 

Inorganic  Chemistry.  In  one  luindaome  octavo  volnme  of  000  pagoH,  with  51 
woodcuts  and  2  litliogriiphic  pltitoH.     Cloth,  $1175;  leather,  |4. 75.     TnprenH. 

This  work  on  ch^iientary  cherniKtry  is  hased  upon  princifjles  of  chxssification,  nomen- 
clatui'o  and  notation  which  IiavcJheon  proved  by  nearly  twenty  years  experience  in  teaching 
to  impart  most  readily  a  sound  and  accurate  knowledge  of  the  science. 

ATTFIELJy,  jrOJIN,lPli'  D., 

Profensor  of  Praciicnl  Chemistry  to  the  Pharmaceutical  Society  of  Orcnt  Britain,  etc. 

Chemistry,  General,  Medical  and  Pharmaceutical ;  Including  the  Chem- 
istry of  the  U.  B.  Pharraacopojia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  tenth 
English  edition,  specially  revised  by  the  Author.  In  one  handsome  royal  12mo.  volume 
of  728  pages,  with  87  illustrations.     Cloth,  $2.50 ;  leather,  $3.00. 

to  put  himself  in  the  stufle-nt's  piano  and  to  appre- 
ciate his  stato  of  mind. — American  Chcfnical  Jour- 
nal, April,  1884. 


A  text-book  which  passes  through  ten  editions 
in  sixteen  years  must  have  good  qualities.  This 
remark  is  certainly  applicable  to  Attfield's  Chem- 
istry, a  booli  which  is  so  well  Icnown  that  it  is 
iiardly  necessary  to  do  more  than  note  the  appear- 
ance of  this  new  and  improved  edition.  It  seems, 
however,  desirable  to  point  out  that  feature  of  the 
book  which,  in  all  probability,  has  made  it  so 
popular.  There  can  be  little  doubt  that  it  is  its 
thoroughly  practical  character,  tlie  expression 
being  used  in  its  best  sense.  The  author  under- 
stands what  the  student  ought  to  learn,  and  is  able 


It  is  a  book  on  which  too  much  praise  cannot  be 
bestowed.  As  a  text-book  for  medical  sofiools  it 
is  unsurpassable  in  the  present  state  of  chemical 
science,  and  having  been  prepared  with  a  special 
view  towards  medicine  and  pharmacy,  it  is  alike 
indispensable  to  all  persons  eng.aged  in  those  de- 
partments of  science.  It  includes  the  whole 
chemistry  of  the  lastl'harmacopoeia. — Pacific  Medi- 
cal anil  Siigrical  Jnurnal,  Jan.  1884. 


BLOXAM,  CHABLFS  X., 

Professor  of  Cliemistry  in  King's  College,  London, 

Chemistry,  Inorganic  and  Organic.  New  American  from  the  fifth  Lon- 
don edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $3.75;  leather,  $4.75. 


Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypotlieses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 
quence that  the  student  never  has  occasion  to 
complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  to  experimental  illustrations  of 
chemical  principles  and  phenomena,  and  the 
mode  of  conducting  these  experiments.  The  book 
maintains  the  position  it  has  always  held  as  one  of 


the  best  manuals  of  general  chemistry  in  the  Eng- 
lish language. — Detroit  Lancet,  Feb.  1S84. 

The  general  plan  of  this  work  remains  the 
same  as  in  previous  editions,  the  evident  oVjject 
being  to  give  clear  and  concise  descriptions  of  all 
known  elements  and  of  their  most  important 
compounds,  with  explanations  of  the  chemical 
laws  and  principles  involved.  We  gladly  repeat 
now  the  opinion  we  expressed  about  a  former 
edition,  that  we  regard  Bloxam's  Chemistry  as 
one  ot  the  best  treatises  on  general  and  applied 
chemistry. — American  Jour,  of  Pharmacy,  Dec.  1883. 


SIMON,  W,,  Ph,  J}.,  M.  n., 

Professor  of  Chemistry  and  Toxicology  m  the  College  of  Physicians  and  Surgeons,  Baltimore,  and 

Professor  of  Chemistry  in  the  Maryland  College  of  Pharmacy. 
Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
In  one  8vo.  vol.  of  410  pp.,  with  16  woodcuts  and  7  plates,  mostly  of  actual  deposits, 
with  colors  illustrating  56  of  the  most  important  chemical  reactions.  Cloth,  $3.00 ;  also 
without  plates,   cloth,  $2.50.     Just  ready. 


This  book  supplies  a  want  long  felt  by  students 
of  medicine  and  pharmacy,  and  is  a  concise  but 
thorough  treatise  on  the  subject.  The  long  expe- 
rience of  the  author  as  a  teacher  in  schools  of 
medicine  and  pharmacy  is  conspicuous  in  the 
perfect  adaptation  of  the  work  to  Ine  special  needs 
of  the  student  of  these  branches.     The  colored 


plates,  beautifully  executed,  illustrating  precipi- 
tates of  various  reactions,  form  a  novel  and  valu- 
able feature  of  the  book,  and  cannot  fail  to  be  ap- 
preciated by  both  student  and  teacher  as  a  help 
over  the  hard  places  of  the  science.— 3/ari/^ana 
Medical  Journal,  Nov.  22,  1884. 


MFMSFW,  IMA,  M,  D.,  Ph,  !>., 

Professor  of  Chemistry  in  the  Johj^  Hopkins  University,  Baltimore. 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.  Second  and  revised  edition.  In  one  handsome  royal  12mo. 
volume  of  240  pages.     Cloth,  $1.75.     Just  ready. 


The  book  is  a  valuable  contribution  to  the  chemi- 
cal literature  of  instruction.  That  in  so  few  years 
a  second  edition  has  been  called  for  indicates  that 
many  chemical  teachers  have  been  found  ready 
to  endorse  its  plan  and  to  adopt  its  methods.  lin 
this  edition  a  considerable  proportion  of  the  book 
has  been  rewritten,  much  new  matter  lias  been 
added  and  the  whole  has  been  brought  up  to  date. 
We  earnestly  commend  this  book  to  every  student 


of  chemistry.  The  high  reputation  of  the  author 
assures  its  accuracy  in  all  matters  of  fact,  and  its 
judicious  conservatism  in  matters  of  theory,  com- 
bined with  the  fulness  with  which,  in  a  small 
compass,  the  present  attitude  of  chemical  science 
towards  the  constitution  of  compounds  is  con- 
sidered, gives  ita  value  much  beyond  that  accorded 
to  the  average  text-books  of  the  day. — American 
Journal  of  Science,  March,  1884. 


10  Lea  Brothers  &  Co.'s  Publications — Chemistry. 

CSABLES,  T,  CUANSTOVJSr,  M.  D.,  F,  C,  S.,  M.  S., 

Formerly  Asst.  Prof,  and  Demonst.  of  Chemistry  and  Chemical  Physics,  Queen's  College,  Belfast. 

The  Elements  of  Physiological  and  Pathological  Chemistry.     A 

Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  463  pages,  witli  38  woodcuts  and  1  colored  plate.     Cloth,  |3.50. 


The  work  is  thoroughly  trustworthy,  and  in- 
formed throughout  by  a  genuine  scientific  spirit. 
The  author  deals  with  the  chemistry  of  the  diges- 
tive secretions  in  a  systematic  manner,  which 
leaves  nothing  to  be  desired,  and  in  reality  sup- 
plies a  want  in  English  literature.  The  book  ap- 
pears to  us  to  be  at  once  full  and  systematic,  and 
to  show  a  just  appreciation  of  the  relative  import- 
ance of  the  various  subjects  dealt  with. — British 
Medical  Journal,  November  29, 18S4. 


Dr.  Charles'  manual  admirably  fulfils  its  inten- 
tion of  giving  his  readers  on  the  one  hand  a  sum- 
mary, comprehensive  but  remarkably  compact,  of 
the  mass  of  facts  in  the  sciences  which  have  be- 
come indispensable  to  the  physician ;  and,  on  the 
other  hand,  of  a  system  of  practical  directions  so 
minute  that  analj'ses  often  considered  formidable 
may  be  pursued  by  any  intelligent  person. — 
Archives  of  Medicine,  Dec.  1884. 


B.OFFMAWW,  F.,  A.M.,  JPh.JD.,  &  FOWFM  F.B.,  Fh.D., 

Public  Analyst  to  the  State  of  Neio  York.  Prof,  of  Anal.  Cheni.  in  the  Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.    Cloth,  $4.25. 


We  congratulate  the  author  on  the  appearance 
of  the  third  edition  of  this  work,  jiublished  for  the 
■first  time  in  this  country  also.  It  is  admirable  and 
the  information  it  undertaljes  to  supi)ly  is  both 
extensive  and  trustworthy.  The  selection  of  pro- 
cesses for  determining  the  purity  of  the  substan- 
ces of  which  it  treats  is  excellent  and  the  descrip- 


tion of  them  singularly  explicit.  Moreover,  it  is 
exceptionally  free  from  typographical^rrors.  We 
have  no  hesitation  in  recommending  it  to  those 
who  are  engaged  either  in  the  manufacture  or  the 
testing  of  medicinal  chemicals. — London  Pharma- 
ceutical Journal  and  Transactions,  1883. 


CLOWES,  FMANK,  D.  Sc,  London, 

Senior  Science- Master  at  the  High  School,  Newcastle-under-Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  very  handsome  royal  12mo.  volume  of  about  400  pages,  with  about  50  illustrations. 
Cloth,  12.50.     In  a  few  days. 

The  d  emand  for  four  editions  of  this  work  proves  the  success  of  Professor  Clowes'  effort 
to  provide  a  simple,  concise  and  trustworthy  guide  to  qualitative  analysis.  The  use  and 
preparation  of  apparatus,  and  the  directions  for  working  have  been  so  fully  and  clearly 
detailed  that  the  book  is  admirably  adapted  not  onl}^  to  relieve  the  teacher  of  unnecessary 
labor,  but  also  to  answer  all  the  requirements  of  self-instruction. 

BALFF,  CMAMLFS  M.,  M.  D.,  F.  M.  C.  F., 

Assistaiit  Physician  at  the  London  Hospital. 
Clinical  Chemistry.     In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 
illustrations.     Limp  cloth,  red  edges,  $1.50.     See  Students'  Series  of  Manuals,  page  3. 


This  is  one  of  the  most  instructive  little  works 
that  we  have  met  with  in  a  long  time.  The  author 
is  a  physician  and  physiologist,  as  well  as  a  chem- 
ist, consequently  the  book  is  unqualifiedly  prac- 
tical, telling  the  physician  just  what  he  ouglit  to 
know,  of  the  applications  of  chemistry  in  medi- 


cine. Dr.  Ralfe  is  thoroughly  acquainted  with  the 
latest  contributions  to  his  science,  and  it  is  quite 
refreshing  to  find  the  subject  dealt  with  so  clearly 
and  simply,  yet  in  such  evident  harmony  with  the 
modern  scientific  methods  and  spirit. — Medical 
Record,  February  2, 1884. 


CLASSFJS-,  ALFXANDFB, 

Professor  in  the  Royal  Polytechnic  School,  Aix-la-Chapelle. 

Elementary  Quantitative  Analysis.  Translated,  with  notes  and  additions,  by 
Edgar  F.  Smith,  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.     In  one  12mo.  volume  of  324  ptges,  with  36  illust.     Cloth,  |2.00. 


It  is  probably  the  best  manual  of  an  elementary 
nature  extant  insomuch  as  its  methods  are  the 
best.  It  teaches  by  examples,  commencing  with 
single    determinations,    followed  by  separations, 


and  then  advancing  to  the  analysis  of  minerals  and 
such  products  as  are  met  with  in  applied  chemis- 
try. It  is  an  indispensable  book  for  students  in 
chemistry. — Boston  Journal  of  Chemistry,  Oct.  1878. 


GBFFWF,  WILLIAM  M.,  M.  D., 

Demonstrator  of  Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania. 

A  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  Based  upon  Bow- 
man's Medical  Chemistry.  In  one  12mo.  volume  of  310  pages,  with  74  illus.  Cloth,  $1.75. 
It  is  a  concise  manual  of  three  hundred  pages,  I  the  recognition  of  compounds  due  to  pathological 
giving  an. excellent  summary  of  the  best  methods  conditions.  The  detection  of  poisons  is  treated 
of  analyzing  the  liquids  and  solids  of  the  body,  both  with  sufficient  fulness  for  the  purpose  of  thestu- 
forthe  estimation  of  their  normal  constituents  and  |  dentor  practitioner. — Boston  Jl.  of  C%e»i.,  June, '80. 


Lea  Brothers  &  Co.'s  Publications— Pharni.,  Mat.  Med.,Therap.  11 


PABJRISM,  MDWAHn, 

Late  Professor  of  the  Theory  and  Practice  of  Pha/rmacy  in  the  Philwlelphia  Colleye  of  Pharmacy. 
A  Treatise  on  Pharmacy :   designed  as  a  Text-book  for  the  Student,  and  'dn  a 
Guide  for  the  Physician  and  Pharmaceutist.     Witli  many  Formulae  and   Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wikoani),  Ph.G.      In  one  liandsome 
octavo  volume  of  1093  i)ages,  with  2-")6  illustrations.     Cloth,  $5  ;  Icatlier,  $6. 


No  tlioronghgoing  phannacistwill  fail  to  posse.ss 
himself  of  so  useful  a  guide  to  practice,  and  no 
physician  who  properly  estimates  Iho  value  of  an 
accurate  knowledge  of  the  remedial  agents  em- 
ployed by  him  in  daily  practice,  so  far  as  their 
miscibility,  compatibility  and  most  effective  meth- 
ods of  combination  are  concerned,  can  afford  to 
leave  this  work  out  of  the  list  of  their  works  of 
reference.  The  country  practitioner,  who  must 
always  bo  in  a  measure  his  own  pliarmacist,  will 
find    it   indispensable. — Louisville   Medical   News, 


Each  page  bears  evidence  of  tlie  oaro  bestowed 
upon  it,  and  conveys  vaUiablo  information  from 
the  rich  store  of  the  editor's  experience.  In  fact, 
all  that  relates  to  practical  pharmacy— apparatus. 
processes  and  dispensing — has  been  arranged  ana 
described  with  clearness  in  its  various  aspects,  so 
as  to  afford  aid  and  advice  alike  to  the  studentand 
to  the  practical  pharmacist.  The  work  is  judi- 
ciously illustratea  with  good  woodcuts — American 
Journal  of  Pharmacy,  .Taniiai-y,  IHSi. 
There  is  nothing  to  equal   Parrish's  PAar-wacj/ 


March  29, 1S84.  I  in  this  or  any  other  language. — London  Pharma- 

This  well-known  work  presents  itself  now  based    ccutical  Journal. 
upon    the    recently  revised  new   Pharmacopceia.  | 


BMUWTOJV,  T,  LAJUJEM,  M,  I),, 

Lecturer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomew's  Hospital,  London,  etc. 

A  Text-book  of  Pharmacology,  Materia  Medica  and  Therapeutics. 

In  one  handsome  octavo  volume  of  about  1000  pages,  with  over  200  illustrations.     Cloth, 
$5.50 ;  leather,  $6.50.     In  press. 

It  is  with  peculiar  pleasure  that  the  early  appearance  of  this  long  expected  work  is 
announced  by  the  publishers.  Written  hy  the  foremost  authority  on  its  subject  in  Eng- 
land, it  forms  a  compendious  treatise  on  materia  medica,  pharmacology,  pharmacy,  and 
the  practical  use  of  medicines  in  the  treatment  of  disease.  Space  has  been  devoted  to  the 
fundamental  sciences  of  chemistry,  physiology  and  pathology,  wherever  it  seemed  necessary 
to  elucidate  the  proper  subject-matter  of  the  book.  A  general  index,  an  index  of  diseases 
and  remedies,  and  an  index  of  bibliography  close  a  volume  which  will  undoubtedly  be  of 
the  highest  value  to  the  student,  practitioner  and  pharmacist. 

HEMMAmS-,  D}\  l7, 

Professor  of  Physiology  in  the  University  of  Zurich. 
Experimental  Pharm.aeology.  A  Handbook  of  Methods  for  Determining  the 
Physiological  Actions  of  Drugs.  Translated,  with  the  Author's  permission,  and  with 
extensive  additions,  by  Hobert  Meade  Smith,  M.  D.,  Demonstrator  of  Physiology  in  the 
Universitv  of  Pennsylvania.  In  one  handsome  12mo.  volume  of  199  pages,  with  32 
illustrations.     Cloth,  $1.50. 


Prof  Hermann's  handbook,  which  Dr.  Smith  has 
translated  and  enriched  with  many  valuable  addi- 
tions, will  be  gladly  welcomed  by  those  engaged  in 
this  department  of  physiology.  It  is  an  excellent 
little  book,  full  of  concise  information,  and  it 
should  find  a  place  in  every  laboratory.    It  ex- 


plains the  various  methods  and  instruments  used, 
and  points  out  what  lines  of  investigation  are  to 
be  pursued  for  studying  different  phenomena, 
and  also  how  and  what  particularly  to  observe. — 
A/nerican  Journal  of  the  Medical  Sciences,  Jan.  18S1. 


MAISCH,  JOJBTJSTM.,  JPhar,  !>., 

Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 

A  Mianual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  New  (second)  edition.  In  one  handsome  royal  12mo.  volume  of  550 
pages,  with  242  illustrations.     Cloth,  $3.00.     Just  ready. 

This  work  contains  the  substance, — the  practical 
"kernel  of  the  nut"  picked  out,  so  that  the  stu- 
dent has  no  superfluous  labor.  He  can  confidently 
accept  what  this  work  places  before  him,  without 
any  fear  that  the  gist  of  the  matter  is  not  in  it. 


Another  merit  is  that  the  drugs  are  placed  before 
him  in  such  a  manner  as  to  simplifj'  very  much 
the  study  of  them,  enabling  the  mind  to  grasp 
them  more  readily.    The  illustrations  are  most 


excellent,  being  very  true  to  nature,  and  are  alone 
worth  the  price  of  the  book  to  the  student.  To  the 
practical  pnysician  and  pharmacist  it  is  a  valuable 
work  for  handy  reference  and  for  keeping  fresh 
in  the  memory  the  knowledge  of  materia  medica 
and  botany  already  acquired.  We  can  and  do 
heartily  recommend  it. — Medical  and  Surgical  Re- 
porter, Feb.  14, 1SS5. 


BRUCE,  J,  MITCSELL,  M.  J>.,  F,  B.  C.  P., 

Physician  and  Lecturer  oyi  Materia  Medica  and  Therapeutics  at  Charing  Cross  Hospital,  London. 
Materia   Medica  and  Therapeutics.    An  Introduction  to  Eational  Treat- 
ment.    In  one  pocket-size  12mo.  volume  of  555  pages.     Limp  cloth,  $1.50,     Just  ready. 

See  Students'  Series  of  Manuals,  page  3. 

One  of  the  very  latest  works  upon  Materia  j  recommend  it  as  one  of  the  very  best  for  either 
Medica  and  Therapeutics,  replete  with  informa-  medical  student  or  practitioner  of  medicine. — 
tiou    abreast  -of    the    times,    we    unhesitatingly  |  Cincinnati  Medical  Keus,  August,  ISSi. 

GBIFFITS,  MOBEBT  EGLESFIELD,  M.  D, 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  and  Adminis- 
tering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceut- 
ists. Third  edition,  thoroughly  revised,  with  numerous  additions,  by  Johjc  M.  IVIaisch, 
Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
In  one  octavo  volume  of  775  pages,  with  3S  illustrations.     Cloth,  $4.50 ;  leather  §5.50. 


12         Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therap. 
STILLB,  A.,  M.I),,LL.J>.,  &  MAISCM,  J.  M.,  JPJiar.  D,, 

Professor  Emeritus  of  the  Theory  and  Prac-  Prof,  of  Mat.  Med.  and  Botany  in  Phila. 

tice  of  Medicine  and  of  Clinical  Medicine  College  of  Pharmacy,  Sec'y  to  the  Ameri- 

in  the  University  of  Pennsylvania.  can  Pharmaceutical  Association. 

The  !N"ational  Dispensatory :  Containing  the  Natural  History,  Chemistry,  Phar- 
macy, Actions  and  Uses  of  Medicines,  including  those  recognized  in  the  Pharmacopoeias  of 
the  United  States,  Great  Britain  and  Germany,  with  numerous  references  to  the  French 
Codex.  Third  edition,  thoroughly  revised  and  greatly  enlarged.  In  one  magniiicent 
imperial  octavo  volume  of  1767  pages,  with  311  hne  engravings.  Cloth,  $7.25; 
leather,  $8.00 ;  half  Russia,  open  back,  $9.00.  With  Denison's  "  Ready  Keference  Index  " 
$1.00  in  addition  to  price  in  any  of  above  styles  of  binding.     Just  ready. 

In  the  j^resent  revision  the  authors  have  labored  incessantly  with  the  view  of  making 
the  third  edition  of  The  National  Dispensatoby  an  even  more  complete  represen- 
tative of  the  pharmaceutical  and  therapeutic  science  of  1884  than  its  first  edition  was  of 
that  of  1879.  For  this,  ample  material  has  been  afforded  not  only  by  the  new  United 
States  Pharmaco2)ceia,  but  by  those  of  Germany  and  France,  which  have  recently  appeared 
and  have  been  incorporated  in  the  Dispensatory,  together  with  a  large  number  of  new  non- 
ofiicinal  rem.edies.  It  is  thus  rendered  the  representative  of  the  most  advanced  state  of 
American,  English,  French  and  German  pharmacology  and  therapeutics.  The  vast  amount 
of  new  and  important  material  thus  introduced  may  be  gathered  from  the  fact  that  the 
additions  to  this  edition  amount  in  themselves  to  the  matter  of  an  ordinary  full-sized  octavo 
volume,  rendering  the  work  larger  by  twenty-five  per  cent,  than  the  last  edition.  The 
Therapeutic  Index  (a  feature  peculiar  to  this  work),  so  suggestive  and  convenient  to  the 
practitioner,  contains  1600  more  references  than  the  last  edition — the  General  Index 
3700  more,  making  the  total  number  of  references  22,390,  while  the  list  of  illustrations 
has  been  increased  by  80.  Every  effort  has  been  made  to  prevent  undue  enlargement  of 
the  volume  by  having  in  it  nothing  that  could  be  regarded  as  superfluous,  yet  care  has 
been  taken  that  nothing  should  be  omitted  Avliich  a  pharmacist  or  physician  could  expect 
to  find  in  it. 

The  appearance  of  the  work  has  been  delayed  by  nearly  a  year  in  consequence  of  the 
determination  of  the  authors  that  it  should  attain  as  near  an  approach  to  absolute  ac- 
curacy as  is  humanly  possible.  With  this  view  an  elaborate  and  laborious  series  of 
examinations  and  tests  have  been  made  to  verify  or  correct  the  statements  of  the  Pharma- 
copceia,  and  very  numerous  corrections  have  been  found  necessary.  It  has  thus  been  ren- 
dered indispensable  to  all  who  consult  the  Pharmacopoeia. 

The  work  is  therefore  presented  in  the  full  expectation  that  it  will  maintain  the 
position  universally  accorded  to  it  as  the  standard  authority  in  all  matters  pertaining  to 
its  subject,  as  registering  the  furthest  advance  of  the  science  of  the  day,  and  as  embody- 
ing in  a  shape  for  convenient  reference  the  recorded  results  of  human  experience  in  the 
laboratory,  in  the  dispensing  room,  and  at  the  bed-side. 


Comprehensive  in  scope,  vast  in  design  and 
splendid  in  execution,  The  JSTational  Dispensatory 
may  be  justly  regarded  as  the  most  important  work 
of  its  kind  extant. — Louisville  Medical  News,  Dec. 
6, 1884. 

We  have  much  pleasure  in  recording  the  appear- 
ance of  a  third  edition  of  this  excellent  work  of 
reference.  It  is  an  admirable  abstract  of  all  that 
relates  to  chemistry,  pharmacy,  materia  medica, 
pharmacology  and  therapeutics.  It  may  be  re- 
garded as  embodying  the  Pharmaeopceias  of  the 
civilized  nations  of  the  world,  all  being  brought 


up  to  date.  The  work  has  been  very  well  done,  a 
large  number  of  extra-pharmacopoeial  remedies 
having  been  added  to  those  mentioned  in  previous 
editions. — London  Lancet,  Nov.  22,  1884. 

Its  completeness  as  to  subjects,  the  comprehen- 
siveness of  its  descriptive  language,  the  thorough- 
ness of  the  treatment  of  the  topics,  its  brevity  not 
sacrificing  the  desirable  features  of  information 
for  which  such  a  work  is  needed,  make  this  vol- 
ume a  marvel  of  excellence. — Pharmaceutical  Re- 
cord, Aug.  15, 1884. 


FAMQVMAMSOW,  BOBEMT,  M.  D., 

Lecturer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School. 

A  Guide  to  Therapeutics  and  Materia  Medica.  Third  American  edition, 
specially  revised  by  the  Author.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia  by 
Feank  Woodbxjby,  M.  D.     In  one  handsome  12mo.  volume  of  524  pages.     Cloth,  $2.25. 


Dr.  Farquharson's  Therapeutics  is  constructed 
upon  a  plan  which  brings  before  the  reader  all  the 
essential  points  with  reference  to  the  properties  of 
drugs.  It  impresses  these  upon  him  in  such  away 
as  to  enable  him  to  take  a  clear  view  of  the  actions 
of  medicines  and  the  disordered  conditions  in 
which  they  must  prove  useful.    The  double-col- 


umned pages — one  side  containing  the  recognized 
physiological  action  of  the  medicine,  and  the  other 
the  disease  in  which  observers  (who  are  nearly  al- 
ways mentioned)  have  obtained  from  it  good  re- 
sults— make  a  very  good  arrangement.  The  early 
chapter  containing  rules  for  prescribing  is  excel- 
lent.— Canada  Med.  and  Surg.  Journal,  Dec.  1882. 


STILLJE,  ALFMEJD,  M,  D.,  LL,  !>,, 

Professor  of  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  ofPenna. 
Therapeutics  and  Materia  Medica.     A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal  Agents,  including  their  Description   and  History.     Fourth   edition, 
revised  and  enlarged.     In  two  large  and  handsome  octavo  volumes,  containing  1936  pages. 
Cloth,  $10.00 ;  leather,  $12.00 ;  very  handsome  half  Russia,  raised  bands,  $13.00. 

We  can  hardly  admit  that  it  has  a  rival  in  the    in  pharmacodynamics,  but  as  by  far  the  most  eom- 
multitude  of  its  citations  and  the  fulness  of  its    plete  treatise  upon  the  clinical  and  practical  side 
research  into  clinical  histories,  and  we  mustassign    of  the  question. — Boston  Medical  and  Surgical  Jour- 
it  a  place  in  the  physician's  library;  not,  indeed,    nai,  Nov.  5j  1874. 
as  fully  representin  g  the  present  state  of  knowledge 


Lea  Brothers  &  Co.'s  Publications — Pathol.,  HiHtol. 


13 


COATS,  JOSBPJI,  M.  J>.,  I\  F.  JP.  S., 

Pathologist  to  the  QlnHijow  Wc.nlarn  Injlrmnry. 
A  Treatise  on  Pathology.     In  one  very  liandsome  octavo  volume  of  829  pages, 
with  339  beautiful  illustrations.     Cloth,  15.50;  leather,  10.50. 


The  work  before  ns  treats  the  snbjont  of  PaHi- 
ology  more  exteriHivcIy  than  it  in  usually  treated 
in  similar  works.  Medical  students  as  well  as 
physicians,  wlio  desire  a  worlc  for  study  or  refer- 
ence, tliat  treats  the  sulijects  in  the  various  de- 
partments in  a  very  thoro'ugli  manner,  biitwithout 
prolixity,  will  certainly  give  this  one  the  prefer- 
ence to  any  with  which  wo  are  ac<iuainl,ed.  Jt  sets 
fortli  tlie  most  recent  discoveries,  exhibits,  in  an 
interesting  manner,   tlie  cliauges  from  a  normal 


condition  eflected  in  strneturcs  by  discafle,  and 
points  out  tlie  characteristics  of  various  morhid 
aKcncies,  so  tliat  ihcy  can  be  easily  recognized.  Hut, 
not  limited  to  morijid  anatomy, ilexplairisfully  bow 
the  functions  of  organs  are  distiirtiod  by  abnoi  inal 
conditions.  There  is  nothing  belonging  U>  its  dc- 
partmentof  medicine,  that  is  notas  fully  elucidated 
asourpre^ent  knowli'dge  will  admit.— Cincinnati 
Medical  Newn,  Oct.  laaa. 


GBBEIf,  T.  MBNIIY,  M.  J)., 

Lecturer  on  Patliologi/  mid  Morbid  AnaUnny  at  Charing-Cross  Jlospilal  Medical  School,  London. 
Pathology  and  Morbid  Anatomy.     Fifth  American  from  the  sixth  revised 
and  enlarged  English  edition.     In  one  very  liandsome  octavo  volume  of  482  pages,  with 
150  fine  engravings.     Cloth,  |2.50.     Just  ready. 
The  fact   that  this  woll-linown  treatise  lias   so 


rapidly  reached  its  sixth  edition  is  a  strong  evi- 
dence of  its  popularity.  The  author  is  to  be  con- 
gratulated upon  the  thoroughness  with  which  lie 
has  prepared  this  work.  It  is  thoroughly  abreast 
with  all  the  most  recent  advances  in  pathology. 


No  work  in  the  English  language  is  so  admirabljr 
adapted  to  the  wants  of  the  student  and  practi- 
tioner as  this,  and  we  would  recommend  it  most 
earnestly  to  every  one. — Nashville  Journal  of  Medi- 
cine and  Surijery,  Nov.  1884. 


WOODHEAIf,  G.  SIMS,  M,  D.,  F.  JR.  C.  J?.  B., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 
Practical  Pathology.     A  Manual  for  Students  and  Practitioners. 
tiftil  octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations. 


In  one  beau- 
Cloth,  $6.00. 


It  forms  a  real  guide  for  the  student  and  practi- 
tioner M'ho  is  thoroughly  in  earnest  in  his  en- 
deavor to  see  for  himself  and  do  for  himself.  To 
the  laboratoiy  student  it  will  be  a  helpful  com- 
panion, and  all  those  who  may  wish  to  familiarize 
themselves  with  modern  methods  of  examining 
morbid  tissues  are  strongly  urged  to  provide 
themselves  with  this  manual.  The  numerous 
drawings  are  not  fancied  pictures,  or  merely 
schematic  diagrams,  but  they  represent  faithfully 
the  actual  images  seen  under  the    microscope. 


The  author  merits  all  praise  for  having  produced 
a  valuable  work. — Medical  Record,  May  31,  1884. 

It  is  manifestly  the  product  of  one  who  ha>  him- 
self travelled  over  the  whole  field  and  who  is  .'^killed 
not  merely  in  the  art  of  histology,  but  in  tlie  oV^ser- 
vation  and  interpretation  of  morbid  changes.  The 
work  is  sure  to  command  a  wide  circulation.  It 
should  do  much  to  encourage  the  pursuit  of  path- 
ology, since  such  advantages  in  histological  study 
have  never  before  been  otfered. —  The  Lancet,  Jan. 
5,  1884. 


SCHAFBB,  BJyWAMD  A.,  F.  B.  S., 

Assistant  Professor  of  Physiology  in  University  College,  London. 

The  Essentials  of  Histology.  In  one  octavo  volume  of  about  300  pages, 
with  about  325  illustrations.     In  press. 

COBWIL,  v.,  and  BAJSmBB,  L., 

Prof,  in  the  Faculty  of  Med.  of  Paris.  Prof,  in  the  College  of  France, 

A  Manual  of  Pathological  Histology.  Translated,  with  notes  and  additions, 
by  E.  O.  Shakespeare,  M.  D.,  Pathologist  and  Ophthalmic  Surgeon  to  Philadelphia 
Hospital,  and  by  J.  Henry  C.  Simes,  M.  D.,  Demonstrator  of  Pathological  Histology  in 
the  University  of  Pennsylvania.  In  one  very  handsome  octavo  volume  of  800  pages,  with 
360  illustrations.    Cloth,  |5.50  ;  leather,  |6.50 ;  half  Kussia,  raised  bands,  $7. 

KLBIJSr,  B.,  M,  D.,  F,  B.  S., 

Joint  Lecturer  on  General  Anat.  and  Phys.  in  the  Med,  School  of  St.  Bartholomew's  Hosp.,  London. 

Elements  of  Histology.   Inonepocket-sizel2mo.  volume  of  360  pages,  with  181 

illus.    Limp  cloth,  red  edges,  $1.50.    See  Students^  Series  of  Manuals,  page  3. 

Although  an  elementary  work,  it  is  by  no  means 
superficial  or  incomplete,  for  the  author  presents 
in  concise  language  nearly  all  the  fundamental  facts 
regarding  tlie  microscopic  structure  of  tissues. 


The  illustrations  are  numerous  and  excellent.  We 
commend  Dr.  Klein's  Elements  most'  heartily  to 
the  student. — Medical  Becord,  Dec.  1, 1883. 


FBFFBB,  A.  J.,  M.  B.,  M.  S.,  F.  B,  C,  S., 

Surgeon  and  Lecturer  at  St.  Mary''s  Hospital,  London, 
Surgical  Pathology.     In  one  pocket-size  12mo.  volume  of  511  pages,  with  81 
illustrations.  Limp  cloth,  red  edges,  $2.00.     See  Students'  Series  ofllanuais,  page  3. 

It  is  not  pretentious,  but  it  will  serve  exceed- 
ingly well  as  a  book  of  reference.  It  embodies  a 
great  deal  of  matter,  extending  over  the  whole 
field  of  surgical  pathology.  Its  form  is  practical, 
its  language  is  clear,  and  the  information  set 
forth   is   well-arranged,    well-indexed   and  well- 


illustrated.  The  student  will  find  in  it  nothing 
that  is  unnecessary.  The  list  of  subiects  covers 
the  whole  range  of  surgery.  The  book  supplies  a 
very  manifest  want  and  should  meet  with  suc- 
cess.— New  York  Medical  Journal,  May  31, 1SS4. 


SCHAFER'S  PRACTICAL  HISTOLOGY.  In  one  I  OGT.  Translated  by  Joseph  Leidt,  M.  D.  In  one 
handsome  royal  12mo.  volume  of  308  pages,  with  I  volume,  very  large  imperial  quarto,  with  32© 
40  illustrations.  1  copper-plate  figures,  plain  and  colored  and  des- 

GLUGE'S  atlas  of  pathological  HISTOL-  I  cnptive  lett€r-prese.    Cloth,  $4.00. 


14 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 


FLINT,  AUSTIN,  M.  !>., 

Prof,  of  the  Principles  a?id  Practice  of  Med.  and  of  Clin.  Med,  in  Bellevue  Hospital  Medical  College,  N.  F. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 
the  use  of  Students  and  Practitioners  of  Medicine.  With  an  Appendix  on  the  Eesearches 
of  Koch,  and  their  bearing  on  the  Etiology,  Pathology,  Diagnosis  and  Treatment  of 
Phthisis.  Fifth  edition,  revised  and  largely  rewritten  In  one  large  and  closely-printed 
octavo  volume  of  1160  pages.    Cloth,  $5.50 ;  leather,  $6.50 ;  half  Eussia,  $7. 

Koch's  discovery  of  the  bacillus  of  tubercle  gives  promise  of  being ^  the  greatest 
boon  ever  conferred  by  science  on  humanity,  surpassing  even  vaccination  in  its  benefits  to 
mankind.  In  the  appendix  to  his  work,  Professor  Flint  deals  with  the  subject  from  a 
practical  standpoint,  discussing  its  bearings  on  the  etiology,  pathology,  diagnosis,  prog- 
nosis and  treatment  of  pulmonary  phthisis.  Thus  enlarged  and  completed,  this  standard 
work  will  be  more  than  ever  a  necessity  to  the  physician  who  duly  appreciates  the  re- 
sponsibility of  his  calling. 


A  well-known  writer  and  lecturer  on  medicine 
recently  expressed  an  opinion,  in  the  highest  de- 
gree complimentary  of  the  admirable  treatise  of 
Dr.  Flint,  and  in  eulogizing  it,  he  described  it  ac- 
curately as  "readable  and  reliable."  No  text-book 
is  more  calculated  to  enchain  the  interest  of  the 
student,  and  none  better  classifies  the  multitudi- 
nous subjects  included  in  it.  It  has  already  so  far 
won  it3  way  in  England,  that  no  inconsiderable 
number  of  men  use  it  alone  in  the  studyof  pure 
medicine;  and  we  can  say  of  it  that  it  is  in  every 
way  adapted  to  serve,  not  only  as  a  complete  guide, 
but  also  as  an  ample  instructor  in  the  science  and 
practice  of  medicine.  The  style  of  Dr.  Flint  is 
always  polished  and  engaging.  The  work  abounds 
in  perspicuous  explanation,  and  is  a  most  valuable 
text-book  of  medicine. — London  Medical  Neics. 


This  work  is  so  widely  known  and  accepted  as 
the  best  American  text-book  of  the  practice  of 
medicine  that  it  would  seem  hardly  worth  while  to 
give  this,  the  fifth  edition,  anything  more  than  a 
passing  notice.  But  even  the  most  cursory  exami- 
nation shows  that  it  is,  practically,  much  more 
than  a  revised  edition ;  it  is,  in  fact,  rather  a  new 
work  throughout.  This  treatise  will  undoubtedly 
continue  to  hold  the  first  place  in  the  estimation 
of  American  physicians  and  students.  No  one  of 
our  medical  writers  approaches  Professor  Flint  in 
clearness  of  diction,  breadth  of  view,  and,  what  we 
regard  of  transcendent  importance,  rational  esti- 
mate of  the  value  of  remedial  agents.  It  is  thor- 
oughly practical,  therefore  pre-eminently  the  book 
for  American  readers. — St.  Louis  Clin,  Bee,  Mar.  '81. 


MAMTSMORNE,  MBNRT,  M.  J>.,  LL.  !>., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Students  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.     Cloth,  $2.75 ;  half  bound,  $3.00. 

Within  the  compass  of  600  pages  it  treats  of  the 
history  of  medicine,  general  pathology,  general 
symptomatology,  and  physical  diagnosis  (including 
laryngoscope,  ophthalmoscope,  etc.),  general  ther- 
apeutics, nosology,  and  special  pathology  and  prac- 
tice. There  is  a  wonderful  amount  of  information 
contained  in  this  work,  and  it  is  one  of  the  best 
of  its  kind  that  we  have  seen. — Glasgow  Medical 
Journal,  Nov.  1882. 

An  indispensable  book.  No  work  ever  exhibited 
a  better  average  of  actual  practical  treatment  than 


this  one ;  and  probably  not  one  writer  in  our  day 
had  a  better  opportunity  than  Dr.  Hartshorne  for 
condensing  all  the  views  of  eminent  practitioners 
into  a  12mo.  The  numerous  illustrations  will  be 
very  useful  to  students  especially.  These  essen- 
tials, as  the  name  suggests,  are  not  intended  to 
supersede  the  text-books  of  Flint  and  Bartholow, 
but  they  are  the  most  valuable  in  aflfbrding  the 
means  to  see  at  a  glance  the  whole  literature  of  any 
disease,  and  the  most  valuable  treatment. — Chicago 
Medical  Journal  and  Examiner,  April,  1SS2. 


BMISTOWE,  JOHN  STEM,  31,  2>.,  F.  jK.  C.  F,, 

Physician  and  Joint  Lecturer  on  Medicine  at  St.  Thomas'  Hospital. 
A  Treatise  on  the  Practice  of  Medicine.     Second  American  edition,  revised 
by  the  Author.    Edited,  with  additions,  by  James  H.  Hutchinson,  M.D.,  physician  to  the 
Pennsylvania  Hospital.     In  one  handsome  octavo  volume  of  1085  pages,  with  illustrations. 
Cloth,  $5.00 ;  leather,  $6.00 ;  very  handsome  half  Eussia,  raised  bands,  $6.50. 

The  reader  will  find  every  conceivable  subject  I  are  appropriate  and  practical,  and  greatly  add  to 
connected  with  the  practice  of  medicine  ably  pre-    its  usefulness  to  American  Tea,deTS.— Buffalo  Med- 
sented,  in  a  style  at  once  clear,  interesting  and    ical  and  Surgical  Journal,  March,  1880. 
concise.    The  additions  made  by  Dr.  Hutchinson  | 


WATSON,  SIM  TM03IAS,  M.  !>., 

Late  Physician  in  Ordinary  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  A  new  American 
from  the  fifth  English  edition.  Edited,  with  additions,  and  190  illustrations,  by  Henry 
Habtshoene,  a.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
In  two  large  octavo  volumes  of  1840  pages.     Cloth,  $9.00  ;  leather,  $11.00. 


LECTURES  ON  THE  STUDY  OF  FEVER.  By 
A.  HiTDSON,  M.  D.,  M.  R.  I.  A.  In  one  octavo 
volume  of  308  pages.    Cloth,  $2.50. 

STOKES'  LECTURES  ON  FEVER.  Edited  by 
John  William  Moore,  M.  D.,  F.  K.  Q.  C.  P.  In 
one  octavo  volume  of  280  pages.    Cloth,  $2.00. 


A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  C.  C.     In  one  8vo.  vol.  of  354  pp.    Cloth,  $2.25. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in 
its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  large  and  hand- 
some octavo  volumes  of  1468  pp.    Cloth,  $7.00. 


A   CENTURY  OF  AMERICAN  MEDICINE,  1776—1876.     By  Drs.  E.  H.  Clarke,  H.  J. 
BiGELOw,  S.  D.  Gross,  T.  G.  Thomas,  and  J.  S.  Billings.    In  one  12mo.  volume  of  370  pages.    Cloth,  $2.25. 


Lea  Brotheus  &  Co.'s  Publications — Systems  of  Med.  1 5 

For  Hale  hy  Suhscriptiovi  Oiiily. 


A  System  of  Practical   Medicine. 

BY  AMERICAN  AUTHORS. 

Edited  by  WILLIAM   PEPPER,  M.  D.,  LL.  D.,     • 

PROVOST  AND  PKOFESSOR  OF  THE  THEORY   AND   PRACTICE  OP  MEDICINE  AND   OF 
CLINICAL  MEDICINE  IN  THE  XJNIVEliSITY  OF  PENNSYLVANIA, 

Assisted  by  Louis  Starr,  M.  D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania. 

In  five  imperial  octavo  volumes,  conhdninc/  about  1100  pages  each,  with  illustrations.     Price  per 
volume,  cloth,  $5 ;    leather,  $6  ;    half  Russia,  raised  hands  and  open  buck,  $7.     Volume  I. 
(General  Pathology,  Sanitary  Science  and  General  Diseases)  contains  1094  pages, 
with  24  illustrations  and  is  ju'st  ready.      Volume  II.  (General  Diseases  [con- 
tinued] and  Diseases  of  the  Digestive  System)  will  be  ready  June  1st, 
and  the  subsequent  volumes  at  intervals  of  four  months  thereafter. 

The  publishers  feel  pardonable  pride  in  announcing  this  magnificent  work.  For 
three  years  it  has  been  in  active  preparation,  and  it  is  now  in  a  sufficient  state  of  forward- 
ness to  .justify  them  in  calling  the  attention  of  the  profession  to  it  as  the  work  in  which 
for  the  first  time  American  medicine  is  thoroughly  represented  by  its  worthiest 
teachers,  and  presented  in  the  full  development  of  the  practical  utility  which  is  its 
preeminent  characteristic.  The  most  able  men — from  the  East  and  the  AVest,  from  the 
North  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  opportunities  of  study  and  practice — have  united  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience. 

The  distinguished  editor  has  so  apportioned  the  work  that  each  author  has  had 
assigned  to  him  the  subject  which  he  is  peculiarly  fitted  to  discuss,  and  in  which  his  views 
will  be  accepted  as  the  latest  expression  of  scientific  and  practical  knowledge.  The 
practitioner  will  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aspect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  treatment  of  special  disease.  So  wide  is  the  scope  of  the 
work  that,  with  the  exception  of  midwifery  and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinary 
organs,  of  the  skin,  of  the  nerves,  hygiene  arid  sanitary  science,  and  medical  ophthalmology 
and  otology.  Moreover,  authors  have  inserted  the  formulas  which  they  have  found  most 
efficient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  as  a 
Complete  Library  of  Practical  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount  of  practical  information  fur- 
nished, it  has  been  impossible  to  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5500  beautifully  printed  pages,  and  embodying  the  matter  of  about  15  ordinary 
octavos.    Illustrations  are  introduced  wherever  they  serve  to  elucidate  the  text. 

As  material  for  the  work  is  substantially  complete  in  the  hands  of  the  editor,  the  pro- 
fession may  confidently  await  the  appearance  of  the  remaining  volumes  upon  the  dates 
above  specified.  A  detailed  pi'ospectus  of  the  work  will  be  sent  to  any  addi-ess  on  appli- 
cation to  the  publishers. 

It  is  a  large  undertaking,  but  quite  justifiable  in  this  country  as  authorities  on  the  particular  topics 
the  case  of  a  progressive  nation  like  the  United  on  which  they  deal,  whilst  the  others  show  by  the 
■States.  At  any  rate,  if  we  may  judge  of  future  way  they  have  handled  their  subjects  that  they 
Tolumes  from  the  first,  it  will  be  justified  by  the  are  fully  equal  to  the  task  they  had  undertaken, 
result.  We  have  nothing  but  praise  to  bestow  *  *  * '  A  work  which  we  cannot  doutet  will  make 
upon  the  work.  The  articles  are  the  work  of  a  lasting  reputation  for  itself. — London  Medical 
writers,  many  of  whom  are  already  recognized  in  \  Times  and  Gazette,  May  9, 18S5. 

BJEYWOZDS,  J.  MUSS  JELL,  M,  J>., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 
A  System  of  Medicine.  With  notes  and  additions  by  Henry  Hartshorne, 
A.  M.,  M.  D.,  late  Professor  cf  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  3056  double-columned  pages,  with  317  illustra- 
tions. Price  per  volume,  cloth,  $5.00 ;  sheep,  |6.00 ;  very  handsome  half  Eussia,  raised  bands, 
$6.50.     Per  set,  cloth,  $15 ;  leather,  $1S ;  half  Kussia,  $19.50.     Sold  only  by  subscription. 

There  is  no  medical  work  which  we  have  in  1  himself  in  need  of.  In  order  that  any  deficiencies 
times  past  more  frequently  and  fully  consulted  i  mav  be  supplied,  the  publishers  have  committed 
when  perplexed  by  doubtsf  as  to  treatment,  or  bv  ;  the  preparation  of  the  book  for  the  press  to  Dr. 
having  unusual  or  apparently  inexplicable  svmp-  Henrv  Hartshorne.  whose  judicious  notes  distrib- 
toms  presented  to  us,  than  "Reynolds'  System  of  uted  'throughout  the  volume  afford  abundant  evi- 
Medicine."  It  contains  just  that  kind  of  informa-  denee  of  the  thoroughness  of  the  revision.— .i*H«r- 
tion  which  the  busy  practitioner  frequently  finds    icnn  Journcl  of  the  Medical  Sciences,  Jan.  1880. 


16  Lea  Brothers  &  Co.'s  Publications — Clinical  Med.,  etc. 

STILLB,  ALFUBJy,  M.  D.,  XX.  D., 

Professor  Emeritus  of  the  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 

Cholera:  Its  Origin,  History,  Causation,  Symptoms,  Prevention  and  Treatment. 
In  one  handsome  12mo.  volume  of  about  175  pages,  with  a  chart.     Cloth,  $1.25.    Shortly. 

The  threatened  importation  of  cholera  into  the  country  renders  peculiarly  timely 
this  work  of  an  authority  so  eminent  as  Professor  Stills.  The  history  of  previous  epi- 
demics, their  modes  of  propagation,  the  vast  recent  additions  to  our  knowledge  of  the 
causation,  prevention  and  treatment  of  the  disease,  all  have  been  handled  so  skilfully  as 
to  present  witji  brevity  the  information  which  every  practitioner  should  possess  in  ad- 
vance of  a  visitation. 


FLINT,  AUSTIN,  M,  X>. 

Clinical  Medicine.  A  Systematic  Treatise  on  the  Diagnosis  and  Treatment  of 
I>iseases.  Designed  for  Students  and  Practitioners  of  Medicine.  In  one  large  and  hand- 
some octavo  volume  of  799  pages.     Cloth,  $4.50 ;  leather,  $5.50 ;  half  Eussia,  $6.00. 


It  is  here  that  the  skill  and  learning  of  the  great 
•clinician  are  displayed.  He  has  given  us  a  store- 
feiouse  of  medical  knowledge,  excellent  for  the  stu- 
dent, convenient  for  the  practitioner,  the  result  of 
sl  long  life  of  the  most  faithful  clinical  work,  col- 
Bected  by  an  energy  as  vigilant  and  systematic  as 
ffiintiring,  and  weighed  by  a  judgment  no  less  clear 
&han  his  observation  is  close. — Archives  of  Medicine, 
Dec.  1879. 

To  give  an  adequate  and  useful  conspectus  of  the 
•extensive  field  of  modern  clinical  medicine  is  a  task 
•of  no  ordinary  difficulty;  but  to  accomplish  this  con- 


sistently with  brevity  and  clearness,  the  different 
subjects  and  their  several  parts  receiving  the 
attention  which,  relatively  to  their  importance, 
medical  opinion  claims  for  them,  is  still  more  diffi- 
cult. This  task,  we  feel  bound'  to  say,  has  been 
executed  with  more  than  partial  success  by  Dr. 
Flint,  whose  name  is  already  familiar  to  students 
of  advanced  medicine  in  this  country  as  that  of 
the  author  of  two  works  of  great  merit  on  special 
subjects,  and  of  numerous  papers  exhibiting  much 
originality  and  extensive  research. — 2  he  Dublin 
Journal,  Dec.  1S79. 


By  the  Same  Author. 

Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.     Cloth,  $1.38. 

JBMOADBBJSTT,  W.  S.,  M.  X>.,  M  M.  C.  I*., 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary^s  Hospital. 
The  Pulse.     In  one  12mo.  volume.     See  Series  of  Clinical  Manuals,  page  3. 

^CSMEIBBM,  DM,  JOSMBH, 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  Waltek  Mendelson,  M.  D.,  of  New  York.  In  one  handsome 
octavo  volume  of  about  300  pages,  with  about  125  fine  engravings.     Preparing. 

FINLAYSON,  JAMBS,  31.  D.,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 
Clinical  Diagnosis.  A  Handbook  for  Students  and  Practitioners  of  Medicine. 
With  Chapters  by  Prof.  Gairdner  on  the  Physiognomy  of  Disease ;  Prof.  Stephens  on 
Diseases  of  the  Female  Organs;  Dr.  Robertson  on  Insanity;  Dr.  Gemmell  on  Physical 
Diagnosis ;  Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor 
on  Case-taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  In 
one  handsome  12mo.  volume  of  546  pages,  with  85  illustrations.     Cloth,  $2.63. 


This  is  one  of  the  really  useful  books.  It  is  at- 
tractive from  preface  to  the  final  page,  and  ought 
to  be  given  a  place  on  every  office  table,  because  it 
contains  in  a  condensed  form  all  that  is  valuable 
in  semeiology  and   diagnostics   to  be  found   in  |  Jan.  1879. 


bulkier  volumes;  and  because  of  its  arrangement 
and  complete  index  it  is  unusually  convenient  for 
quick  reference  in  any  emergency  that  may  come 
upon  the  busy  practitioner. — N.  C,  Med.  Journ., 


FBNWICK,  SAMUBL,  31.  D., 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  a,nd 
enlarged  English  edition.  In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 
87  illustrations  on  wood.     Cloth,  $2.25. 

TANNBM,  TM03IAS  MAWKBS,  M.  D. 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 
from  the  second  London  edition.  Eevised  and  enlarged  by  TiiiBUKY  Fox,  M.  D.,  Phy- 
sician to  the  Skin  Department  in  University  College  Hospital,  London,  etc.  In  one  small 
12mo.  volume  of  362  pages,  wjth  illustrations.     Cloth,  $1.50. 

FOTMBMGILZ,  J.  31.,  31.  D.,  Bdin.,  31.  JR.  C.  P.,  Lond., 

Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics. New  edition.     In  one  octavo  volume.     Preparing. 


STURGES'  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  Being  a  Guide  to 
the  Investigation  of  Disease.  In  one  handsome 
,12mo.  volume  of  127  pages.    Cloth,  $1.25. 


DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES.  By  N.  S.  Davis, 
M.  D.  Edited  by  Frank  H.  Davis,  M.  D.  Second 
edition.    12mo.  287  pages.    Cloth,  $1.75. 


Lea  Brothers  &  Co.'b  Publications — Hygiene,  Eleetr.,  I*ract.        17 


BICHAJinSON,  J?.  TF.,  31. A.,  M.D,,  LL,  J>.,  F.ll.S.,  F,S,A, 

Fellow  of  the  Royal  CoUcr/e  of  Physicians,  London. 

Preventive  Modicine.     In  one  octavo  volume  of  729  pages.     Cloth,  $4;  leather, 
$5;  very  handsome  lialfKiiKHia,  raised  bands,  I^.^O. 

Dr.  Richardson  has  Hiicceedcd  in  producing  a  j  the  quoslion  of  dlflcaselflcomprehenBlve, masterly 
worlc  wliich  isi  elovaU^din  conf.f.ption,  cnmproyif'n-    find  fully  ahroftst  with  tho  latest  and  best  knowl- 

sive  in  sn,opo,s('i(uitifi()  in  character,  syst(irnatio  in    '•' —  '"  "  "  •■"'■ '   — '  " ""'■  —"-"■•-'■'• 

arrangement,  and  which  is  written  in  a  clear,  eon- 
<!ise  and  iileasaiit  manner.  Ho  (evinces  tho  liappy 
faculty  of  extracting  the  pith  of  what  is  linown  on 
the  subject,  and  of  presenting  it  in  a  most  simple, 
intelligent  and  practical  form.  There  is  perhaps 
no  similar  work  written  for  tho  general  public 
thatcontains  su(^h  acomplete, reliable  and  instruc- 
tive collection  of  data  upon  tlio  diseases  common 
to  tho  race,  their  origins,  causes,  and  the  measures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarly;  the  discussion  of 


edge  on  tho  subject,  and  the  preventive  measures 
advised  are  accurate,  exp)licit  and  reliable. —  7'he 
American  Journtdof  the  Mi'jUcal  Snienr.en,  April,  1884. 

This  is  a  Vwok  that  will  surely  find  a  place,  on  the 
table  of  every  progressive  physician.  'I'o  the 
medical  profession,  whose  duty  is  quite  as  much  to 
prevent  as  to  cure  diseast!,  the  boot  will  bf!  a  boon. 
—  Boston  MeiUr.al,  and  Surgir.al  Journal,  Mar.  0,  1884. 

The  treatise  contains  a  vast  amount  of  .solid,  valu- 
able hygienic  information. — Medical  and  Surgical 
Ueporter,  Feb.  23, 1884. 


BAMTHOLOW,  BOBBUTS,  A.  M.,  M.  B.,  LL.  J>., 

Prof,  of  Blatcria  Medic.a  and  General  T  lierapeulics  in  the  Jefferson  Med.  Coll.  of  Phil  a.,  etc. 
Medical  Electricity.     A  Practical  Treatise  on  the  Applications  of  Electricity 
to  Medicine  and  Surgery.     Second  edition.     In  one  very  handsome  octavo  volume  of  292 
pages,  with  109  illustrations.     Cloth,  $2.50. 

The  second  edition  of  this  woi-k  following  so 
soon  upon  the  first  would  in  itself  appear  to  be  a 
sufficient  announcement;  nevertheless,  tlie  text 
has  been  so  considerably  revised  and  condensed, 
and  so  much  enlarged  by  the  addition  of  new  mat- 
ter, that  we  cannot  fail  to  recognize  a  vast  improve- 
ment upon  the  former  work.  The  author  has  pre- 
pared his  work  for  students  and  practitioners — for 
those  who  have  never  acquainted  themselves  with 
the  subject,  or,  having  done  so,  find  that  after  a 
time  their  knowledge  needs  refreshing.  We  think 
he  has  accomplished  this  object.  The  book  is  not 
too  voluminous,  but  is  thoroughly  practical,  sim- 
ple, complete  and  comprehensible.  It  is,  more- 
over, replete  with  numerous  illustrations  of  instru- 
ments, appliances,  etc. — Medical  Record,  November 
15, 1882. 


A  most  excellent  work,  addressed  by  a  practi- 
tioner to  his  fellow-practitioners,  and  therefore 
thoroughly  practical.  The  work  now  before  us 
has  the  exceptional  merit  of  clearly  pointing  out 
where  the  benefits  to  be  derived  from  electricity 
must  come.  It  contains  all  and  everything  that 
the  practitioner  needs  ill  order  to  understand  in- 
telligently the  nature  and  laws  of  the  agent  he  is 
makmg  use  of,  and  for  its  proper  application  in 
practice.  In  a  condensed,  practical  form,  it  pre- 
sents to  the  physician  all  that  he  would  wish  to 
remember  after  perusing  a  whole  library  on  medical 
electricity,  including  the  results  of  the  latest  in- 
vestigations. It  is  the  book  for  the  practitioner, 
and  tlie  necessity  for  a  second  edition  proves  that 
it  has  been  appreciated  by  the  profession. — Physi- 
cian and  Surgeon,  Dec.  1882. 


TMB  YEAB'BOOK  OF  TBEAT3IENT. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine.    In  one  12mo.  volume  of  320  pages,  bound  in  limp  cloth,  with  red  edges,  $1.25. 

This  work  presents  to  the  practitioner  not  only  a  complete  classified  account  of  all 
the  more  important  advances  made  in  the  treatment  of  Disease  during  the  year  ending 
Sept.  30,  1884,  but  also  a  critical  estimate  of  the  same  by  a  competent  authority.  Each 
department  of  practice  has  been  fully  and  concisely  treated,  and  into  the  consideration  of 
each  subject  enter  such  allusions  to  recent  pathological  and  clinical  work  as  bear  directly 
upon  treatment.  As  the  medical  literature  of  all  countries  has  been  placed  under  contri- 
bution, the  references  given  throughout  the  work,  together  with  the  separate  indexes  of 
subjects  and  authors,  will  serve  as  a  guide  for  those  who  desire  to  investigate  any  thera- 
peutical topic  at  greater  length. 

The  contributions  are  from  the  pens  of  the  following  well-known  gentlemen: — J. 
Mitchell  Bruce,  M.D.  ;  T.  Lauder  Brunton,  M.D.,  F.R.S.  ;  Thomas  Bryant,  F.R. 
C.S.;  F.  H.  Champneys,  M.B.  ;  Alfred  Cooper,  F.R.C.S.  ;  Sidney  Coupland,  M.D.  ; 
Dyce  Duckworth,  M.D. ;  George  P.  Field,  M.R.C.S.  ;  Reginald  Harrison,  F.R. 
C.S. ;  J.  Warrington  Haward,  F.R.C.S. ;  F.  A.  Mahomed,  M.B.  ;  Malcolm  Morris, 
F.R.C.S.,  Ed.  ;  Edmund  Owen,  F.R.C.S. ;  R.  Douglas  Powell,  M.D. ;  Henry  Power, 
M.B.,  F.R.C.S.;  C.  H.  Ralfe,  M.D. ;  A.  E.  Sansom,  M.D.;  Felix  Semon,  M.D.; 
Walter  G.  Smith,  M.D. ;  J.  Knowsley  Thornton,  M.B. ;  Frederick  Treves, 
F.R.C.S. ;  A.  DE  Watteville,  M.D. ;  John  Williams,  M.D. 


MABBBSBCOJSr,  S.  O.,  31.  B., 

Senior  Physician  to  and  late  Led.  on  Principles  and  Pi-actice  of  Med.  at  O-uy's  Hospital,  London. 
On  the  Diseases  of  the  Abdomen ;     Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  CEsophagus,  Caecum,  Intestines  and  Peritoneum.  Second 
American  from  third  enlarged  and  revised  English  edition.     In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.     Cloth,  $3.50. 


PAVY'S  treatise  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  pages.    Cloth,  $2.00. 

CHAMBERS'  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.    Cloth,  82.75. 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Cokdie, 
M.  D.     1  vol.  8vo.,  pp.  603.     Cloth,  S2.50. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
320  pages.     Cloth,  $2.50. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS.   1  vol.  8vo.,  pp.  493.    Cloth,  $3.50. 


18  Lea  Brothers  &  Co.'s  Publications — Throat,  liiings,  Heart. 

COHEN,  J.  SOLIS,  M.  J>., 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  the  Jefferson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Affections  of  the  Pharynx,  CEsophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustrations.  In 
one  very  handsome  octavo  volume.     Preparing. 


SBILBJR,  CARL,  M.  D., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.  Second  edition.  In  one  handsome  royal  12mo.  volume 
of  294  pages,  with  77  illustrations.     Cloth,  ipl.75. 

It  is  one  of  the  best  of  the  practical  test-books  I  the  essentials  of  diagnosis  and  treatment  in  dis- 
on  this  subject  -with  which  we  are  acquainted.  The  eases  of  the  throat  and  nose.  The  art  of  laryngos- 
present  edition  has  been  increased  in  size,  but  its  copy,  the  anatomy  of  the  throat  and  nose  and  the 
eminently  practical  character  has  been  main-  j  pathology  of  the  mucous  membrane  are  discussed 
tained.  Many  new  illustrations  have  also  been  with  conciseness  and  ability.  The  work  is  pro- 
introduced,  a  ease-record  sheet  has  been  added,  ]  fusely  illustrated,  excels  in  many  essential  feat- 
and  there  are  a  valuable  bibliography  and  a  good  j  ures,  and  deserves  a  place  in  the  office  of  the 
index  of  the  whole.  For  any  one  who  wishes  to  i  practitioner  who  would  inform  liimself  as  to  the 
make  himself  familiar  with  the  practical  manage-  I  nature,  diagnosis  and  treatment  of  a  class  of  dis- 
ment  of  cases  of  throat  and  nose  disease,  the  book  eases  almost  inseparable  from  general  medical 
will  be  found  of  great  value.— iVei«  York  Medical  practice.  With  advanced  students  the  book  must 
Journal,  June  9, 1883.  he  very  popular  on  account  of  its  condensed  style. 

The  work  beforp  .^^  i.?  a  concise  handbook  upon  1  — Louisville  Medical  News,  June  26, 1883. 

BMOWJVB,  LMNNOX,  F.  B,  C.  S.,  Bdin., 

Senior  Surgeon  to  the  Central  London  Tliroat  and  Ear  Hospital,  etc. 
The  Throat  and  its  Diseases,     Second  American  from  the  second  English  edi- 
tion, thoroughly  revised.     With  100  typical  illustrations  in  colors  and  50  wood  engravings, 
designed  and  executed  by  the  Author.     In  one'  very  handsome  imperial  octavo  volume  of 
about  350  pages.     Preparing. 

FLINT,  AUSTIN,  M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  T. 

A  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis  of 
Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Third  edition.  In  one  hand- 
some royal  12mo.  volume  of  240  pages.     Cloth,  $1.63. 


It  is  safe  to  say  that  there  is  'not  in  the  English 
language,  or  any  other,  the  equal  amount  of  clear, 
exact  and  comprehensible  information  touching 
the  physical  exploration  of  the  chest,  in  an  equal 
number  of  words.  Professor  Flint's  language  is 
precise  and  simple,  conveying  without  dubiety 


the  results  of  his  careful  study  and  ample  ex- 
perience in  such  wise  that  the  young  will  find  it  the 
best  source  of  instruction,  and  the  old  the  most 
pleasant  means  of  reviving  and  complementing 
their  knowledge.  —  American  Practitioner,  June, 
1883. 


BY  THE  SAME  A  UTHOR. 

Physical  Exploration  of  the  Lungs  by  Means  of  Auscultation  and 
Percussion.  Three  lectures  delivered  before  the  Philadelphia  County  Medical  Society, 
1882-83.     In  one  handsome  small  12mo.  volume  of  83  pages.     Cloth,  |1.00. 

A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.  Second  and 
revised  edition.     In  one  handsome  octavo  volume  of  591  pages.     Cloth,  $4.50. 

Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis ;  In  a  series  of  Clinical  Studies.  In  one  liandsome  octavo  volume  of  442  pages. 
Cloth,  $3.50.  

A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 
Diseases  of  the  Heart.  Second  revised  and  enlarged  edition.  In  one  octavo  volume 
of  550  pages,  with  a  ]3late.     Cloth,  $4. 

QMOSS,  S.  B.,  M.B.,  LL.B,,  B.C.L.  Oocon.,  LL.B,  Cantab. 

A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.  Intone 
octavo  volume  of  452  pages,  Avith  59  illustrations.     Cloth,  $2.75. 


FULLER  ON  DISEASES  OP  THE  LUNGS  AND 
AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatm^ent.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  $3.50. 

SLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  pp.  1.5S.    Cloth,  $1.25. 

WALSHB  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.    In  1  vol.  8vo.,  416  pp.    Cloth,  $3.00. 


SMITH  ON  CONSUBIPTION;  its  Early  and  Reme- 
diable Stages.    1  vol.  8vo.,  pp.  253.    Cloth,  $2.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  Svo.  of  490 
pages.    Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration.   In  one  Svo.  vol.  of  303  pp.  Cloth,  $2.50. 

JONES'  CLINICAL  OBSERVATIONS  ON  FUNC- 
TIONAL NERVOUS  DISORDERS.  Second  Am- 
erican edition.  In  one  handsome  octavo  volume 
of  340  pages.    Cloth,  $3.25. 


Lea  Brothers  &  Co.'s  Publications — Nerv.  and  Ment.  Dis.,;etc.     19 


MITCHELL,  S.  WBIB,  M.  J>., 

Physician  to  Orthopaadic  Hospital  and  the  Infirmary  for  Diseases  of  the  Nervous  System,  PhiUi.,  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  EHpecially  in  Women. 
Second  edition.     In  one  12mo.  volume  of  288  pages.     Cloth,  §1.7.0.     JvM  rejuly. 

So  great  have  been  the  achievements  of  the  system  perfected  by  the  author  for  the  treat- 
ment of  hysterical  and  nervoii.s  di.seaHOH  that  the  profcKHJon  will  welcome  the  second  and 
enlarged  edition  of  a  work  which  gives  in  detail  the  methods  of  enforced  rest,  massas^c  and 
systematic  feeding  on  wliich  thia  mode  of  treatment  is  based.  Many  of  these  lectures  are 
original  studies  of  well-known  diseases,  and  others  deal  with  suljijects  which  have  been 
hitherto  slighted  in  medical  literature  or  which  are  almost  unknown  to  it. 


The  interest  lies  in  the  keen  insight  into  the 
nature  of  the  subject  and  in  the  suggeHtions  which 
the  author  manages  to  throw  into  his  accounts. 
The    lectures    must   command   the    thoughtful 


attention  and  careful  study  of  all  who  desire  to 
rciid  what  is  best  in  medical  science.— JT/ie  Loiulon 
Lancet,  JMay  Ki,  1S80. 


HAMILTOlSr,  ALLAJ^  lIcLAWJE,  M.  D., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackweWs  Island,  N.  Y. 
Nervous  Diseases ;  Tlieir  Description  and  Treatment.     Second  edition,  thoroughly 
revised  and  rewritten.    In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 


When  the  first  edition  of  this  good  book  appeared 
we  gave  it  our  emphatic   endorsement,  and  the 

E resent  edition  enhances  our  appreciation  of  tlie 
ook  and  its  author  as  a  safe  guide  to  students  of 
clinical  neurology.  One  of  the  best  .and  most 
critical  of  English  neurological  'ournals,  Brain,  has 


characterized  this  book  as  the  best  of  its  kind  In 
any  language,  which  is  a  handsome  endorsement 
from  an' exalted  source.  The  improvements  in  the 
new  edition,  and  the  additions  to  it,  will  justify  its 
purchase  even  by  those  who  po.ssess  the  old. — 
Alienist  and  Neurologist,  April,  1882. 


TTIKE,  DANIEL  MACK,  31.  I)., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  467  pages,  with 
two  colored  plates.     Cloth,  $3.00. 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 
amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomenathe  more  firmly 
has  he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  most  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 
commend  itself  to  every  thoughtful  understand- 
ing.— Neiv  York  Medical  Journal,  September  6, 1884. 


CLOUSTON,  THOMAS  S,,  31.  D.,  F.  M.  C.  JP.,  L.  M.  C.  S., 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 
Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Chables  F.  Folsom,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Medical  Department  of  Harvard  University.  In  one  handsome 
octavo  volume  of  541  pages,  illustrated  with  eight  lithographic  plates,  four  of  which, 
are  beautifully  colored.     Cloth,  §4. 


The  practitioner  as  well  as  the  student  will  ac- 
cept the  plain,  practical  teaching  of  the  author  as  a 
forward  step  in  the  literature  of  insanity.  It  is 
refreshing  to  find  a  physician  of  Dr.  Clouston's 
experience  and  high  reputation  giving  the  bed- 
side notes  upon  which  his  experience  has  been 
founded  .ind  his  mature  judgment  established. 
Such  clinical  observations  cannot  but  be  useful  to 


the  general  practitioner  in  guiding  him  to  a  diag- 
nosis and  indicating  the  treatment,  especially  in 
many  obscure  and  doubtful  cases  of  mental  dis- 
ease. To  the  American  reader  Dr.  Folsom's  Ap- 
pendix adds  greatly  to  the  value  of  the  work,  and 
will  make  it  a  desirable  addition  to  every  library. 
— American  Psychological  Journal,  July,  1884. 


J|@^Dr.  Folsom's  Abstract  may  also  be  obtained  separatelv  in  one  octavo  volume  of 
IDS  pages.     Cloth,  $1.50.       

SAVAGE,  GEOMGE  H.,  31.  D., 

Lecturer  on  Mental  Diseases  at  Guy's  Hospital,  London. 

Insanity  and  Allied  Neuroses,  Practical  and  Clinical.  In  one  12mo.  vol- 
ume of  551  pages,  with  18  typical  illustrations.  Cloth,  $2.00.  Just  ready.  See  Series  oj 
Clinical  Manuals,  page  3. 

As  a  handbook,  a  guide  to  practitioners  and  stu- 
dents, the  book  fulfils  an  admirable  purpose.  The 
many  forms  of  insanity  are  described  with  char- 
acteristic clearness,  the  illustrative  eases  are  care- 
fully selected,  and  as  regards  treatment,  sound 


common  sense  is  everywhere  apparent.  We  re- 
peat that  Dr.  Savage  "has  written  an  excellent 
manual  for  the  practitioner  and  student. — Am- 
erican Journal  of  Insanity,  April,  1SS5. 


PLATEAIB,  W.  S.,  31.  D.,  E.  M.  C.  E., 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria. 

one  handsome  small  12mo.  volume  of  97  phages.     Cloth,  $1.00. 


In 


Blandford  on  Insanity  and  its  Treatment :   Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.    In  one  very  handsome  octavo  volume. 


20 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


GBOSS,  S,  n.,  31.  D,,  LL,  D.,  D.  C.  L.   Oxon.,  ii.  D. 
Cantab,  f 

Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System  of  Surgery :    Pathological,   Diagnostic,  Therapeutic  tfind  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.     In  two  large  and  beautifully- 
printed  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly,  bound  in  leather,  raised  bands,  $15;  half  Eussia,  raised  bands,  $16. 


Dr.  Gross'  St/sfeni  of  Surqery  has  long  been  the 
standard  work  oh  tliat  subject  for  students  and 
practitioners. — London  Lancet,  May  10,  1884. 

The  work  as  a  whole  needs  no  commendation. 
Many  years  ago  it  earned  for  itself  the  enviable  rep- 
utation of  the  leading  American  work  on  surgery, 
and  it  is  still  capable  of  maintaining  that  standard. 
The  reason  for  this  need  only  be  mentioned  to  be 
appreciated.  The  author  has  always  been  calm 
and  judicious  in  his  statements,  has  based  his  con- 
clusions on  much  study  and  personal  experience, 
has  been  able  to  grasp  his  subject  in  its  entirety, 
and,  above  all,  has  conscientiously  adhered  to 
truth  and  fact,  weighing  the  evidence,  pro  and 
con,  accordingly.    A  considerable  amount  of  new 


material  has  been  introduced,  and  altogether  the 
distinguished  author  has  reason  to  be  satisfied 
that  he  has  placed  the  work  fully  abreast  of  the 
state  of  our  knowledge.— i¥ed.  Record,  Nov.  18, 1882. 
His  System  of  Surgery,  which,  since  its  first  edi- 
tion in  1859,  has  been  a  standard  work  in  this 
country  as  well  as  in  America,  in  "the  whole 
domain  of  surgery,"  tells  how  earnest  and  lakiori- 
0U3  and  wise  a  surgeon  he  was,  how  thoroughly 
he  appreciated  the  work  done  by  men  in  other 
countries,  and  how  much  he  contributed  to  pro- 
mote the  science  and  practice  of  surgery  in  his 
own.  There  has  been  no  man  to  whom  America 
is  so  much  indebted  in  this  respect  as  the  Nestor 
of  surgery. — British  Medical  Journal,  Blay  10,  1884. 


ASSMUMST,  JOMW,  Jr.,  3£.  D., 

Professor  of  Clinical  Surgery,  Univ.  of  Penna.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

The  Principles  and  Practice  of  Surgery.  Fourth  edition,  enlarged  and 
revised.  In  one  large  and  handsome  octavo  volume  of  about  1100  pages,  with  about  575 
illustrations.     In  press. 

GOULD,  A.  JPEAMCB,  31.  S.,  31.  B.,  F.  M.  C.  S,, 

Assistant  Surgeon  to  Middlesex  Hospital. 

Elements  of  Surgical  Diagnosis.    In  one  pocket-size  12mo.  volume  of  589 

pages.     Cloth,  $2.00.     Just  ready.         See  Students'  Series  of  Manuals,  page  3. 

and  if  practitioners  would  devote  a  portion  of  their 
leisure  to  the  study  of  it,  they  would  receive 
immense  benefit  in  the  way  of  refreshing  their 
knowledge  and  bringing  it  up  to  the  present  state 
of  progress. — Cincinnati  Medical  News,  Jan.,  1885. 


The  student  and  practitioner  will  find  the 
principles  of  surgical  diagnosis  very  satisfactorily 
set  forth  with  all  unnecessary  verbiage  elimi- 
nated. Every  medical  student  attending  lectures 
should  have  a  copy  to  study  during  the  intervals. 


GIBWBY,  F.  !>.,  31,  J)., 

Surgeon  to  the  Orthopoeaic  Hospital,  New  York,  etc. 
Orthopaedic  Surgery.    For  the  use  of  Practitioners  and  Students.    In  one  hand- 
some octavo  volume,  profusely  illustrated.     Preparing. 

MOBJEMTS,  JOH]^  B.,  A.  31.,  31.  D., 

Lecturer  on  Anatomy  and  on  Operative  Surgery  at  the  Philadelphia  School  of  Anatomy. 

The  Principles  and  Practice  of  Surgery.  For  the  use  of  Students  and 
Practitioners  of  Medicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  about  500 
pages,  with  many  illustrations.     Preparing. 

BBLLA31Y,  BiyWABD,  F.  M.  C.  S., 

Surgeon   and  Lecturer   on  Surgery  at    Charing    Cross  Hospital,  Examiner  in   Anatomy  Royal 
College  of  Surgeons,  London. 

Operative  Surgery.     Shortly.     See  Students'  Series  of  Manuals,  page  3. 


STI3ISON,  BBWIS  A.,  B.  A 

Prof,  of  Pathol.  Anat.  at  the  Univ.  of  the  City 

A  Manual  of  Operative  Surgery, 

of  477  pages,  with  332  illustrations.     Cloth,  |: 

This  volume  is  devoted  entirely  to  operative  sur- 
gery, and  is  intended  to  familiarize  the  student 
with  the  details  of  operations  and  the  different 
modes  of  performing  them.  The  work  is  hand- 
somely illustrated,  and  the  descriptions  are  clear 
and  well-drawn.    It  is  a  clever  and  useful  volume ; 


.,  31.  n., 

of  New  York,  Surgeon  and  Curator  to  Bellevue  Hasp. 
.  In  one  very  handsome  royal  12mo.  volume 
2.50. 

every  student  should  possess  one.  This  work 
does  away  with  the  necessity  of  pondering  over 
larger  works  on  surgery  for  descriptions  of  opera- 
tions, as  it  presents  in  a  nutshell  what  is  wanted 
by  the  surgeon  without  an  elaborate  search  to 
find  it. — Maryland  Medical  Journal,  August,  1878. 


SARGENT  ON  BANDAGING  and  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition, 
with  a  Chapter  on  military  surgery.  One  12mo. 
volume  of  383  pages,  with  187  cuts.    Cloth,  $1.75. 

MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  edition.  In 
one  8vo.  vol.  of  638  pages,  with  340  illustrations. 
Cloth,  13.75. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth 
and  revised  American  from  the  last  Edinburgh 
edition.  In  one  large  8vo.  vol.  of  682  pages,  with 
364  illustrations.    Cloth,  $3.75. 


PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  John  Neill,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.     Cloth,  $3.75. 

COOPER'S  LECTURES  ON  THE  PRINCIPLES 
AND  PRACTICE  OF  SURGERY.  In  one  8vo.to1. 

of  767  pages.    Cloth,  $2.00. 

SKEY'S  OPERATIVE  SURGERY.  In  one  vol.  8vo- 

of  661  pages,  with  81  woodcuts.    Cloth,  $3.25. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF 
SURGERY.  Eighth  edition.  In  two  octavo  vols, 
of  965  pages,  with  34  plates.    Leather  $6.50. 


Lea  Brothers  &  Co.'s  Publications — Surg-ei-y. 


21 


ericitbbn;  joitw  b,,  Bz  n.  s.,  f,  it.  c.  >s'.. 

Professor  of  Suryery  in  University  Collcjc,  London,  etc. 
The  Science  and  Art  of  Surgery;  licin^  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Oi)erations.     1^'rom  the  ciglith  and  enlarged  Englifih  edition.     In  two  large  and 
beautiful    oetavo    volumes   of   231G    pages,    illustrated    with  984  engravings  on  wood. 
Cloth,  |9;  leather,  raised  bands,  $11 ;  half  Ilussia,  raised  bands,  $12.     Jmt  ready. 


After  the  profession  has  placed  its  approval  upon 
a  work  totho  exteiitof  piir(!lianing  seven  editioriw, 
it  does  not  iiee<l  to  be  )nl,rodiio(^d.  SiinuHaneoiis 
with  the  appeai'aiico  of  this  edition  a  translation 
is  being  made  into  Italian  and  HpaiiiHh.  Thus 
this  favorite  text- book  on  surgery  holds  its  own  in 
spito  of  numerous  rivals  at  the  end  of  thirty  years. 
It  is  a  grand  book,  worthy  of  the  art  in  the  interof  t 
of  which  itiswritten.— />c^/•oi<//aHcc('.,  Jan.lO,  1885. 

After  being  before  the  profession  for  thirty 
years  and  maintaining  during  that  period  a  re- 
putation as  a  leading  work  on  surgery,  there  is  not 


mueh  to  be  said  in  the  way  of  comment  or  criti- 
cism. That  it  still  holds  its  own  gocH  withoutsay- 
ing.  The  author  infuses  into  it  liis  largo  experi- 
ence and  ripo  judgment.  Wedded  to  no  school, 
committed  to  no  theory,  biassed  tjy  no  hobby,  he 
imparts  an  honest  personality  in  lijs  observaiions, 
and  his  teachings  are  the  rulings  of  an  impartial 
judge.  Bncli  men  are  always  safe  guides, and  their 
works  stand  the  tests  of  time  and  experience. 
Such  an  author  is  Erichsen,  and  such  a  work  is  his 
Surfjary.— Medical  Record,  Feb.  21, 1885. 


BRYANT,  THOMAS,  F,  M.  C.  S., 

Surgeon  and  Leeturer  on  Surgery  at  Ouy^s  Hospital,  London. 
The  Practice  of  Surgery.     Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.     In  one  large  and  very  handsome  imperial  octavo  volume  of  1040  pages,  with 
727  illustrations.     Cloth,  |6.50;  leather,  $7.50 ;  half  Kussia,  $8.00.     Junt  ready. 


The  treatise  takes  in  the  whole  field  of  surgery, 
that  of  the  eye,  the  ear,  the  female  organs,  ortho- 
peedi'^s,  venereal  diseases,  and  military  surgery, 
as  well  as  more  common  and  general  topics.  All 
of  these  are  treated  with  clearness  and  with 
sufficient  fulness  to  suit  all  practical  purposes. 
Tlie  illustrations  are  numerous  and  well  printed. 
We  do  not  doubt  that  this  new  edition  will  con- 
tinue to  maintain  the  popularity  of  this  standard 
work. — Medical  and  Surgical  Reporter,  Feb.  It,  '85. 


This  most  m.agnificent  work  upon  surgery  has 
reached  a  fourth  edition  in  this  country,  showing 
the  lii^li  appreciation  in  which  it  is  held  tjy  the 
American  pi-ofession.  It  comes  fresh  from  the 
pen  of  the  author.  That  it  is  the  very  V>est  work 
on  surgery  for  medical  -students  we  think 
there  can  be  no  doubt.  The  author  seems  to  have 
understood  just  what  a  student  needs,  and  has 
prepared  the  work  accordingly. — Cincinnati  Medical 
IVews,  January,  1885. 


By  the  same  Author. 
Diseases  of  the  Breast.    In  one  12mo.  volume.   Preparing.   See  Series  of  Clinical 
Manuals,  page  3. 

ESMABCJa,  Dr,  FBIEimiCM, 

Professor  of  Surgery  at  the  University  of  Kiel,  etc. 
Early  Aid  in  Injuries  and  Accidents.     Five  Ambulance  Lectures.     Trans- 
lated by  H.  E.  H.  Princess  Christian.    In  one  handsome  small  12mo.  volume  of  109 
pages,  with  24  illustrations.     Cloth,  75  cents. 


The  course  of  instruction  is  divided  into  five 
sections  or  lectures.  The  first,  or  introductory 
lecture,  gives  a  brief  account  of  the  structure  and 
organization  of  the  human  body,  illustrated  by 
clear,  suitable  diagrams.  The  second  teaches  how 
to  give  judicious  help  in  ordinary  injuries — contu- 
sions, wounds,  haemorrhage  and  poisoned  wounds. 
The  third  treats  of  first  aid  in  cases  of  fracture 
and  of  dislocations,  in  sprains  and  in  burns.    Next, 


the  metliods  of  affording  first  treatment  in  cases 
of  frost-bite,  of  drowning,  of  suffocaiion,  of  loss  of 
consciousness  and  of  poisoning  are  described  ; 
and  the  fifth  lecture  teaches  how  injured  persons 
may  be  most  safely  and  easily  transported  to  their 
homes,  to  a  medical  man,  or  to  a  hospital.  The 
illustrations  in  the  book  are  clear  and  good. — Medi- 
cal Times  and  Gazette,  Nov.  4, 1882. 


TRBVES,  FRFDERICK,  F.  B.  C.  S., 

Assistant  Surgeon  to  and  Lecturer  on  Surgery  at  the  London  Hospital. 

Intestinal  Obstruction.  In  one  pocket-size  12mo.  volume  of  522  pages,  with  60 
illustrations.  Limp  cloth,  blue  edges,  $2.00.  Just  ready.  See  Series  of  Clinical  Manuals, 
page  3. 

A  standard  worlc  on  a  subject  that  has  not  been  I  justice  to  the  author  in  a  few  paragraphs.  Intes- 
so  compretiensively  treated  by  any  contemporary  (inai  Obstruction  is  a  work  tliat  will  prove  of 
English  writer.  Its  completeness  renders  a  full  equal  value  to  the  practitioner,  the  student,  the 
review  difficult,  since  every  chapter  deserves  mi-  pathologist,  the  physician  and  the  operating  sur- 
nute  attention,  and  it  is  impossible  to  do  thorougli  |  geon. — British  Medical  Journal,  Jan." 31, 18S5. 


BALL,  CM  Alt  LBS  B.,  31.  Ch.,  Dili}.,  F.  It.  C.  S.  B., 

Surgeon  and  Teacher  at  Sir  P.  T)un''s  Hospital,  Dublin. 

Diseases  of  the  Rectum  a.nd  Anus.    In  one  12mo.  volume  of   550  pages. 

Preparing.     See  Series  of  Clinical  Manuals,  page  3. 


BUTLIN,  MBNMT  T.,  F.  B.  C.  S., 

Assistant  Surgeon  to  St.  Bartholomew's  Hospital,  London. 

Diseases    of  the    Tongue.     In  one  12mo. 
Manuals,  page  3.     Shorlly. 


volume.       See   Series   of  Clinical 


DMUITT,  ItOBBBT,  31.  B.  C.  S.,  etc. 

The  Principles  and  Practice  of  Modern  Surgery.     From  the  eighth 
London  edition.     In  one  8vo.  volume  of  687  pages,  with  432  illus.     Cloth,  $4 ;  leather,  $5. 


22  Lea  Brothers  &  Co.'s  Publications — Surg-ery. 

MOL3IES,  TIMOTMT,  M.  A.r 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Rospital,  London. 

A  System  of  Surgery ;  Theoretical  and  Practical.  IN  TREATISES  BY 
VAEIOUS  AUTHOES.  American  edition,  ti-iokoughly  revised  and  re-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospitals, 
Philadelphia,  assisted  by  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons. 
In  three  large  and  very  handsome  imperial  octavo  volumes  containing  3137  double- 
columned  pages, -with  979  illustrations  on  wood  and  13  lithographic  plates,  beautifully 
colored.  Price  per  volume,  cloth,  $6.00 ;  leather,  $7.00 ;  half  Eussia,  |7.50.  Per  set,  cloth, 
$18.00 ;  leather,  $21.00 ;  half  Eussia,  $22.50.     Sold  only  by  subscription. 

Volume  I.  contains  General  Pathology,  Morbid  Processes,  Injuries  in  Gen- 
eral, Complications  of  Injuries  and  Injuries  of  Eegions. 

Volume  II.  contains  Diseases  op  Organs  of  Special  Sense,  Circulatory  Sys- 
tem, Digestive  Tract  and  Genito-Urinary  Organs. 

Volume  III.  contains  Diseases  of  the  Eespiratory  Organs,  Bones,  Joints  and 
Muscles,  Diseases  of  the  Nervous  System,  Gunshot  Wounds,  Operative  and 
Minor  Surgery,  and  Miscellaneous  Subjects  (including  an  essay  on  Hospitals). 

This  great  work,  issued  some  years  since  in  England,  has  won  such  universal  confi- 
dence wherever  the  language  is  spoken  that  its  republication  here,  in  a  form  more 
thoroughly  adapted  to  the  wants  of  the  American  practitioner,  has  seemed  to  be  a  duty 
owing  to  the  profession.  To  accomplish  this,  each  article  has  been  placed  in  the  hands  of 
a  gentleman  specially  competent  to  treat  its  subject,  and  no  labor  has  been  spared  to  bring 
each  one  up  to  the  foremost  level  of  the  times,  and  to  adapt  it  thoroughly  to  the  practice 
of  the  country.  In  certain  cases  this  has  rendered  necessary  the  substitution  of  an  entirely 
new  essay  for  the  original,  as  in  the  case  of  the  articles  on  Skin  Diseases,  on  Diseases  of 
the  Absorbent  System,  and  on  Anaesthetics,  in  the  use  of  which  American  practice  differs 
from  that  of  England.  The  same  careful  and  conscientious  revision  has  been  pursued 
throughout,  leading  to  an  increase  of  nearly  one-fourth  in  matter,  while  the  series  of 
illustrations  has  been  nearly  trebled,  and  the  whole  is  presented  as  a  complete  exponent 
of  British  and  American  Surgery,  adapted  to  the  daily  needs  of  the  working  practitioner. 

In  order  to  bring  it  within  the  reach  of  every  member  of  the  profession,  the  five  vol- 
umes of  the  original  have  been  compressed  into  three  by  employing  a  double-columned 
royal  octavo  page,  and  in  this  improved  form  it  is  offered  at  less  than  one-half  the  price  of  the 
original.  It  is  printed  and  bound  to  match  in  every  detail  with  Eeynolds'  System  of  Medi- 
cine. The  work  will  be  sold  by  subscription  only,  and  in  due  time  every  member  of  the 
profession  will  be  called  upon  and  offered  an  opportunity  to  subscribe. 


The  authors  of  the  original  English  edition  are 
men  of  the  front  rank  in  England,  and  Dr.  Packard 
has  been  fortunate  in  securing  as  his  American 
coadjutors  such  men  as  Bartholow,  Hyde,  Hunt, 
Conner,  Stimson,  Morton,  Hodgen,  Jewell  and 
their  colleagues.  As  a  whole,  the  work  will  be 
iBolid  and  substantial,  and  a  valuable  addition  to 


the  library  of  any  medical  man.  It  is  more  wieldly 
and  more' useful  than  the  English  edition,  and  with 
its  companion  work—"  Reynolds'  System  of  Medi- 
cine"— will  well  represent  the  present  state  of  our 
science.  One  who  is  familiar  with  those  two  works 
will  be  fairlv  well  furnished  head-wise  and  hand- 
wise.— T/is  Medical  Keics,  Jan.  7, 1882. 


STIM80JV,  LEWIS  A,,  B,  A.,  M,  J>., 

Professor  of  Pathological  Anatomy  at  the  University  of  the  City  of  New  York,  Surgeon  and  Curator 
to  Mellevue  Hospital,  Surgeon  to  the  Presbyterian  LTospital,  N'eiv  York,  etc. 

A  Practical  Treatise  on  Fractures.    In  one  very  handsome  octavo  volume  of 
598  pages,  with  360  beautiful  illustrations.     Cloth,  $4.75  ;  leather,  $5.75. 

the   surgeon  in  full  practice. — iV".  O.  Medical  and 
Surgical  Journal,  March,  18S3. 

The  author  gives  in  clear  language  all  that  the 
practical  surgeon  need  know  of  the  science  of 
fractures,  their  etiologj"-,  symptoms,  processes  of 
union,  and  treatment,  according  to  the  latest  de- 
velopments. On  the  basis  of  mechanical  analysis 
the  author  accurately  and  clearly  explains  the 
clinical  features  of  fractures,  and  by  the  same 
method  arrives  at  the  proper  diagnosis  snd  rational 
treatment.  A  thorough  explanation  of  the  patho- 
logical anatomy  and  a  careful  description  of  the 
various  methods  of  procedure  make  the  book  full 
of  value  for  every  pra,etitioner. — Centralhlatt  fur 
Chirurgie,  May  19, 18S3. 


The  author  has  given  to  the  medical  profession 
in  this  treatise  on  fractures  what  is  likely  to  be- 
come a  standard  work  on  the  subject.  It  is  certainly 
not  surpassed  by  any  work  written  in  the  English, 
or,  for  that  matter,  any  other  language.  The  au- 
thor tells  us  in  a  short,  concise  and  comprehensive 
manner,  all  that  is  known  about  his  subject.  There 
is  nothing  scanty  or  superficial  about  it,  as  in  most 
other  treatises ;  on  the  contrary,  everything  is  thor- 
ough. The  chapters  on  repair  of  fractures  and  their 
treatment  show  him  not  only  to  be  a  profound  stu- 
dent, but  likewise  a  practical  surgeon  and  patholo- 
gist. His  mode  of  treatment  of  the  different  fract- 
ures is  eminently  sound  and  practical.  We  consider 
this  work  one  of  the  best  on  fractures ;  and  it  will 
be  welcomed  not  cnly  as  a  text-book,  but  also  by 


MAMSS,  SOWABD,  F.  M.  C.  S., 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London. 
Diseases  of  the  Joints.   In  one  12mo.  volume.   Preparing.   See  Series  of  Clinical 
Manuals,  page  3. 

PICK,  X.  PICKBRING,  F.  It.  C.  8., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 
Fractures  and  Dislocations.     In  one  12mo.  volume.    Preparing.    See  Series 
of  Clinical  Manuals,  page  3. 


Lea  Brothers  &  Co.'s  Publications — Frac,  DiHloc,  Ophthal.      23 


HAMILTON,  FBANKH.,  M,  JD.,  ZL,  D., 

Surgeon  to  Bellevue  UoHpital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  Sevcntd  edition, 
thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998 
pages,  with  379  illustrations.  Cloth,  $5.50 ;  leather,  $6,50 ;  very  handsome  half  liuesia, 
open  back,  $7.00.     Just  ready. 


Hamilton'a  i^reat  experience  and  wide  acquaint- 
ance with  ttie  ntorature  of  the  subject  have  enabled 
him  to  complete  the  labors  of  Malgaigno  and  to 
place  the  reader  in  possession  of  tho  (idvanees 
made  duriug  thirty  years.  The  editions  have  fol- 
lowed each  other  rapidly,  and  they  introduce  us 
to  the  methods  of  practice,  often  so  wise,  of  his 
American  colleagues.  More  practical  than  Blal- 
gaigne's  worlv,  it  will  serve  as  a  valuable  guide  to 
the  practitioner  in  tho  numerous  and  embarrass- 
ing cases  which  come  under  his  observation. — 
Archives  Ginh'ales  do  Medecine,  Paris,  Nov.  1884. 

This  work,  which,  since  its  first  appearance 
twenty-five  years  ago,  has  gone  through  many 
editions,  and  been  Vnucli  enlarged,  may  now  be 
fairly  regarded  as  the  authoritative  hook'  of  refer- 
ence on  the  subjects  of  fractures  and  dislocations. 
Eacli  successive  edition  has  been  rendered  of 
greater  value  through  the  addition  of  more  re- 


cent work,  and  especially  of  the  recorded  re- 
scarciies  and  improvements  made  by  the  author 
himself  and  his  countrymen. — British  Medical 
Journal,,  May  0, 1885. 

With  its  first  appearance  in  IS.TO,  this  work  took 
rank  among  tho  classics  in  medical  literature, 
and  lias  ever  since  boon  quoted  by  surgeons  the 
world  over  as  an  authority  upon  the  topics  of 
which  it  treats.  Tiie  surg(!')n,  if  one  can  be  found 
who  does  not  already  know  the  work,  will  find  it 
scientific,  forcible  and  si;holarIy  in  text,  exhaustive 
in  detail,  and  ever  marked  by  a  spirit  of  wise  con- 
servatism.— Louisville  Medical  News,  .Jan.  10, 188.5. 

For  a  quarter  of  a  century  the  author  has  been 
elaborating  and  perfecting  his  work,  so  that  it 
now  stands  as  the  best  oi  its  kind  in  any  lan- 
guage. As  a  text-book  and  as  a  book  of  reference 
and  guidance  for  practitioners  it  is  simply  invalu- 
able.— Neiv  Orleans  Med.  andSarg.  Journ'l,  Nov.  1884. 


JTILBM,  MJEJSTMY  E,,  F.  M,  C.  S., 

Senior  Ass^t  Surgeon,  Royal  Westini aster  Ophthalmic  Hasp. ;  lat6  Clinical  AssH,  Moorfields,  London. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  In  one  handsome 
octavo  volume  of  460  pages,  with  125  woodcuts,  27  colored  plates,  and  selections  from  the 
Test-types  of  Jaeger  and  Snellen.     Cloth,  $4.50 ;  leather,  $5.50.     Just  ready. 

This  work  is  distinguished  by  tlie  great  num- 
ber of  colored  plates  which  appear  in  it  for  illus- 
trating various  patliological  conditions.  They  are 
very  oeautiful  in  appearance,  and  .have  been 
executed  witli  great  care  as  to  accuracy.  An  ex- 
amination of  the  work  shows  it  to  be  one  of  high 
standing,  one  that  will  be  regarded  as  an  authority 
among  ophthalmologists.  The  treatment  recom- 
mended is  such  as  the  author  lias  learned  from 
actual  experience  to  be  the  best. — Cincinnati  Medi- 
cal News,  Dec.  lSS-4. 

It  presents  to  the  student  concise  descriptions 


and  typical  illustrations  of  all  important  eye 
affections,  placed  in  juxtaposition,  so  as  to  be 
grasped  at  a  glance.  Beyond  a  doubt  it  is  tlie 
best  illustrated  handbook  of  ophthalmic  science 
which  has  ever  appeared.  Then,  what  is  still 
better,  these  illustrations  are  uearl.v  all  original. 
AVe  have  examined  this  entire  work  with  great 
care,  and  it  represents  the  commonly  accepted 
views  of  advanced  ophthalmologists.  We  can  most 
heartily  commend  this  book  to  all  medical  stu- 
dents, practitioners  and  specialists.  —  Detroit 
Lancet,  Jan.  1SS5. 


WELLS,  J.  SOELBEMG,  F.  B.  C,  S,, 

Professor  of  Ophthalmology  in  King's  College  Hospital,  London,  etc. 
A  Treatise  on  Diseases  of  the  Eye.  Fourth  American  from  the  third  London 
edition.  Thoroughly  revised,  with  copious  additions,  by  Charles  S.  Bull,  M.  D.,  Surgeon 
and  Pathologist  to  the  New  York  Eye  and  Ear  Infirmary.  In  one  large  octavo  volume  of 
822  pages,  with  257  illustrations  on  wood,  sis  colored  plates,  and  selections  fi-om  the  Test- 
types  of  Jaeger  and  Snellen.     Cloth,  $5.00 ;  leather,  $6.00  ;  half  Russia,  $6.50. 

The  present  edition  appears  in  less  than  three  j  shows  the  fidelity  and  thoroughness  with  which 
years  since  the  publication  of  the  last  American 
edition,  and  yet,  from  the  numerous  recent  inves- 
tigations that  have  been  made  in  this  branch  of 
medicine,  many  changes  and  additions  have  been 
required  to  meet  the  present  scope  of  knowledge 
upon  this  subject.    A  critical  examination  at  once 


the  editor  has  accomplished  his  part  of  the  work. 
The  illustrations  throughout  are  good.  This  edi- 
tion can  be  recommended  to  all  as  a  complete 
treatise  on  diseases  of  the  eye,  than  which  proba- 
bly none  better  exists. — Medical  Record,  A\ig.  IS, '83. 


JSTETTLESMIP,  EDWAHn,  F.  M,  C.  S,, 

Ophthalmic  Surg,  and  Lect.  on  Ophth.  Surg,  at  St.  Thoinas''  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  Second  edition.  With  a  chap- 
ter on  the  Detection  of  Color-Blindness,  by  William  Thomson,  M.  D.,  Ophthalmologist 
to  the  Jefferson  Medical  College.  In  one  royal  12mo.  volume  of  416  pages,  with  138 
illustrations.     Cloth,  $2.00. 


This  admirable  guide  bids  fair  to  become  the 
favorite  text-book  on  ophthalmic  surgery  with  stu- 
dents and  general  practitioners.  It  bears  tkrough- 
out  tlie  imprint  of  sound  judgment  combined  with 
vast  experience.    Tlie  ilfustratious  are  numerous 


and  well  chosen.  This  book,  within  the  short  com- 
pass of  about  400  pages,  contains  a  lucid  exposition 
of  the  modern  aspect  of  ophthalmic  science. — 
Medical  Record,  June  23, 1883. 


BMOWNE,  EUGAM  A., 

Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary  a)id  to  the  Dispensary  for  Skin  Diseases. 

How  to  Use  the  Ophthalmoscope.  Being  Elementary  Instructions  in  Oph- 
thalmoscopy, arranged  for  the  use  of  Students.  In  one  small  royal  12mo.  volume  of  116 
pages,  with  35  illustrations.     Cloth,  $1.00. 


LAWSON  ON  INJURIES  TO  THE  EYE.  ORBIT 
AND  EYELIDS:  Their  Immediate  and  Remote 
Effects.    8  vo.,  404  pp.,  02  illus.     Cloth,  §3.50. 

LAITRENCE  AND  MOON^S  HANDY  BOOK  OF 
OPHTHALMIC  SURGERY,  for  the  use  of  Prac- 


titioners.   Second  edition.    In  one  octavo  vol- 
ume of  227  pages,  with  65  illust.     Cloth,  S2.75. 
CARTICR'S  PRACTICAL  TREATISE  ON  DISEAS- 
ES OF  THE  EYE.    Edited  by  John  Gbeex,  M.  D. 
In  one  handsome  octavo  voliime. 


:24         Lea  Brothers  &  Co.'s  Publications — Otol.,  XJrin.  I>is.,Deiit. 
BVBNBTT,  CHARLBS  M.,  A,  M.,  M.  D., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic ;  President  of  the  American  Otological  Society. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  Treatise 
■for  the  use  of  Medical  Students  and  Practitioners.  New  (second)  edition.  In  one  handsome 
■octavo  volume  of  580  pages,  with  107  illustrations.   Cloth,  $4.00;  leather,  |5.00.  Just  ready. 

carried  out,  and  much  new  matter  added.    Dr. 


We  note  with  pleasure  the  appearance  of  a  second 
■edition  of  this  valuable  work.  When  it  first  came 
out  it  was  accepted  by  the  profession  as  one  of 
the  standard  works  on  modern  aural  surgery  in 
the  English  language;  and  in  his  second  edition 
Dr.  Burnett  has  fully  maintained  his  reputation, 
for  the  book  is  replete  with  valuable  information 
and  suggestions.    Tlie  revision  has  been  carefully 


Burnett's  work  must  be  regarded  as  a  very  valua- 
ble contribution  to  aural  surgery,  not  only  on 
account  of  its  comprehensiveness,  but  because  it 
contains  the  results  of  the  careful  personal  observa- 
tion and  experience  of  this  eminent  aural  surgeon. 
— London  Lancet,  Feb.  21, 1885. 


POLITZEU,  ADAM, 

Imperial- Royal  Prof,  of  Aural  Therap.  in  the  Univ.  of  Vienna. 

A  Text-Book  of  the  Ear  and  its  Diseases.  Translated,  at  the  Author's  re- 
quest, by  James  Patterson  Cassells,  M.  D.,  M.  K.  C.  S.  In  one  handsome  octavo  vol- 
ume of  800  pages,  with  257  original  illustrations.     Cloth,  $5.50. 

The  work  itself  we  do  not  hesitate  to  pronounce 
the  best  upon  the  subject  of  aural  diseases  which 
has  ever  appeared,  systematic  without  being  too 
diffuse  on  obsolete  subjects,  and  eminently  prac- 
'tical  in  every  sense.  Tlie  anatomical  descriptions 
of  each  separate  division  of  the  ear  are  admirable, 
and  profusely  illustrated  by  woodcuts.  They  are 
followed  immediately  by  the  physiology  of  the 


section,  and  this  again  by  the  pathological  physi- 
ology, an  arrangement  which  serves  to  keep  up  the 
interest  of  the  student  by  showing  the  direct  ap- 
plication of  what  has  preceded  to  the  study  of  dis- 
ease. The  whole  work  can  be  recommended  as  a 
reliable  guide  to  the  student,  and  an  efficient  aid 
to  the  practitioner  in  his  treatment. — Boston  Medr 
ical  and  Surgical  Journal,  June  7, 1883. 


MOBBMTS,  WILLIAM,  M.  D., 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Fourth  American  from  the  foui'th  London  edition.  In  one  liand- 
some  octavo  volume  of  about  650  pages,  with  81  illustrations.     Cloth,  |3.50.     Just  ready. 

This  excellent  book  has  now  reached  its  fourth 
edition,  and  not  too  soon,  for  the  third  has  been 
exhausted  for  some  years,  and  it  is  one  of  those 


works  which  no  good  physician's  or  surgeon's 
library  should  be  without.     The  profession  is  sin- 


cerely to  be  congratulated  that  he  has  been  able 
amidst  his  many  public  and  private  duties  to  pre- 
sent a  new  edition  of  this  standard  work, 
thoroughly  brought  up  to  the  present  date. — Lon- 
don Medical  Record,  May  15, 1885. 


GMOSS,  S.  D.,  M.  !>.,  LL.  J>.,  J>.  C.  X.,  etc. 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra,  Third 
•  edition,  thoroughly  revised  by  Samuel  W.  Gross,  M.  D.,  Professor  of  the  Principles  of 
Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  Philadelphia.  In  one 
octavo  volume  of  574  pages,  with  170  illustrations.     Cloth,  |4.50. 

MORRIS,  SB  WRY,  M.  B.,  F.  R.  C,  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 

Surgical  Diseases  of  the  Kidney.  In  one  12mo.  volume.  Preparing.  See 
■Series  of  Clinical  Manuals,  page  3. 

LUCAS,  CLBMBJSTT^M.  B.,  B.  S.,  F.  R.  C.  S., 

Senior  Assistant  Surgeon  to  Guy's  Hospital,  London. 
Diseases   of  the   Urethra.      In   one    12mo.   volume.     Preparing.     See  Series 
■  of  Clinical  Manuals,  page  3. 

TSOMFSON,  SIR  SBJS^RT, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.     In  one  8vo.  volume  of  203  pp.,  with  25  illustrations.     Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Fistulse.     From  the  third  English  edition.     In  one  octavo  volume  of  359 
pages,  with  47  cuts  and  3  plates.     Cloth,  $3.50. 

COLBMAW,  A,,  L.  R.  C.  F.,  F.  R,  C,  S.,  Bxam.  L,  D.  S,, 

Senior  Dent.  Surg,  and  Lect.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hosp.,  London. 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
■adapted  to  the  use  of  American  Students,  by  Thomas  C.  Stellvs^agen,  M.  A.,  M,  D., 
D.  D.  S.,  Prof,  of  Physiology  at  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.     Cloth,  $3.25. 

iBASHAM    on    renal    diseases  :   A   Clinical    I    ome  12mo.  vol.  of  304  pages,  with  21  illustrations. 
Guide  to  their  Diagnosis  and    Treatment.    In    |    Cloth,  82.00. 


Lea  Brothers  &  Co.'s  ]*ublications — Venereal,  Impotence. 


25- 


BJJMSTEAJy,  F.  J., 

M.  JJ.,  LL.  />., 

Late  Professor  of  Vcneredl  Diseases 
at  the  Col/nf/e  of  Pkysicmns  and 
Surgeons,  New  York,  etc. 


and  TAYLOR,  M.  TT., 

A.  M.,  M.  n,, 

Surgeon  to  Chari/i/  H'osjiil/U,  Ken;  York,  Prof,  of 
Venereal  and  Skin  J>ijieaHeH  in  the  Univergily  of 
Vermont,  Pres.  of  the  Am.  iJermalological  Ass'n, 


The  Pathology  and  Treatment  of  Venereal  Diseases.  Indufling  the 
results  of  recent  investigations  upon  tiie  Huhject.  Fil'tli  edition,  reviseil  <in<\  largely  re- 
written, by  Dr.  Taylor.  In  one  large  and  handsome  octavo  vohiirie  of  808  f»ageH  with 
139  illustrations,  an<l  thirteen  cliromo-lithograi)liic  figures.  Cloth,  $4.75;  leather,  $5.75; 
very  handsome  half  Kiissia,  |G.25. 

It  i.s  a  .'(plendid  record  of  lioneat  labor,  wide 
research,  just  comparison,  careful  scrutiny  and 
original  expei'ience,  wliich  will  always  bo  held  as 
a  high  credit  to  American  medical  literature.  This 
is  uot  only  the  best  work  in  the  English  language 
upon  the  subjects  of  which  it  (rents,  but  also  one 
wiiich  has  no  equal  iu  other  tongues  fen-  its  clear, 
comprehensive  and  practical  handling  of  its 
themes. — Ainerican  Journal  of  the  Medical  Sciences, 
Jan,  1884. 

It  is  certainly  the  best  single  treatise  on  vene- 
real in  our  own,  and  probably  the  best  in  any  lan- 
guage.— Boston  Medical  and  Surgical  Journal,  April 
3,  ISS-i. 


The  character  of  this  standard  work  is  bo  well 
known  that  it  would  bo  superlhious  here  to  pass  in 
review  its  general  or  special  points  of  excellence. 
The  verdict  of  the  profession  iias  been  psissed;  it 
has  Vjcen  accepted  as  the  most  thorough  and  com- 
plete e-xposilion  of  the  patliology  and  (realmentof 
vcneieal  diseases  in  the  language.  Adrnii-ableas  a- 
model  of  clear  description,  an  exponent  of  sound 
pathological  doctrine,  and  a  guide  for  rational  and 
succcKsful  treatment,  itisanornamenttoiho  medi- 
cal literature  of  this  country.  Tiieadditi(Mis  made 
to  the  present  edition  are  eminently  judicious, 
from  the  standpoint  of  practical  utility. — Journal  of 
Cutaneous  and  Venereal  Diseases,  Jan.  1884. 


JErUTCHIJSrSOW,  JOWATHAW,  F,  Jl.  S.,  F.  M.  c.  s., 

Consulting  Surgeon  to  the  London  Hospital. 
Syphilis.    In  one  12mo.  volume.   Preparimj.    See  Series  of  Clinical  Manuah,  page  3. 


COMJVIL,  F., 

Pi'ofcssor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lourcine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Speciallj 
revised  by  the  Autlior,  and  translated  with  notes  and  additions  by  J.  Henry  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  University  of  Pennsylvania,  and 
J.  William  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  Surgery 
in  the  University  o^"  Pennsylvania.  In  one  handsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustrations.  Cloth,  $3.75. 
The  anatomical  and  histological  characters  of  the 


hard  and  soft  sore  are  admirably  described.  The 
multiform  cutaneous  manifestations  of  the  disease 
are  dealt  with  histologically  in  a  masterly  way,  as 
we  should  indeed  expect  them  to  be,  and  the 
accompanying  illustrations  are  executed  carefully 
and  well.  The  various  nervous  lesions  which  are 
the  recognized  outcome  of  the  syphilitic  dyscrasia 
are  treated  with  care  and  consideration.  Syphilitic 
epilepsy,  paralysis,  cerebral  syphilis  and  locomotor 
ataxia  are  subjects  full  of  interest;  and  nowhere  in 


the  whole  volume  is  the  clinical  experience  of  the 
author  or  the  wide  acquaintance  of  the  translators 
with  medical  literature  more  evident.  The  anat- 
omy, the  histology,  the  pathology  and  the  clinical 
features  of  syphilis  are  represented  in  this  work  in 
their  best,  most  practical  and  most  instructive 
form,  and  no  one  will  rise  from  its  perusal  without 
the  feeling  that  his  grasp  of  the  wide  and  impor- 
tant subject  on  whicli  it  treats  is  a  stronger  and 
surer  one. — The  London  Practitioner,  Jan.  1882. 


GMOSS,  SA3IJIEL  W,,  A.  31.,  M.  !>., 

PYofessor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  Second  edition,  thoroughly  revised.  In  one  very  hand- 
some octavo  volume  of  168  pages,  with  16  illustrations.     Cloth,  $1.50. 


The  author  of  this  monograph  is  a  man  of  posi- 
tive convictions  and  vigorous  style.  This  is  iusti- 
fied  by  his  experience  and  by  his  study,  which  has 
gone  liand  in  hand  with  his  experience.  In  regard 
to  the  various  organic  and  functional  disorders  of 
the  male  generative  apparatus,  he  has  had  ex- 
ceptional opportunities  for  observation,  and  l:is 
book  shows  that  lie  has  not  neglected  to  compare 
his  own  views  with  tliose  of  other  authors.  The 
result  is  a  work  which  can  be  safely  recommended 


This  work  will  derive  value  from  the  high  stand- 
ing of  its  author,  aside  from  the  fact  of  its  passing 
so  rapidly  into  its  second  edition.  This  is,  indeed, 
a  book  that  every  physician  will  be  glad  to  place 
in  his  library,  to  be  read  with  profit  to  himself, 
and  with  incalculable  benefit  to  his  patient.  Be- 
sides the  subjects  embraced  in  the  title,  which  are 
treated  of  in  their  various  forms  and  degrees, 
spermatorrhoea  and  prostatorrhcea  are  also^" fully 
considered.    The  work  is  thoroughly  practical   in 


to  both  physicians  and  surgeons  as  a  guide  in  the    character,  and  will  be  especially  useful  to 


treatment  of  the  disturbances  it  refers  to.  It  i: 
the  best  treatise  on  the  subject  with  which  we  are 
acquainted. —  7Vie  Medical  Kcws,  Sept.  1, 1883. 


general   practitioner. — Medical    liecord,  Aus 
1883. 


the 
IS, 


CULLEMIEB.,  A.,  &  BUMSTEAD,  F.  J.,  3I.I>.,  EE.J)., 

Surgeon  to  the  Ildpital  da  Midi.  Late  Professor  of  Venereal  Diseases  in  the  College  of  Physieian» 

and  Surgeons,  New  York. 

An  Atlas  of  Venereal  Diseases.  Translated  and  edited  by  Free>[an  J.  Bum- 
stead,  M.  D.  Iu  one  imperial  4to.  vohmie  of  328  pages,  double-cohimns,  with  26  plates, 
containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of  life.  Strongly 
bound  in  cloth,  $17.00.    A  specimen  of  the  plates  and  text  sent  by  mail,  on  receipt  of  25  cts. 

HILL  ON  SYPHILIS  AND  LOCAL  COIvTAGIOUS  ;  FORjrS    OP     LOCAL     DISEASE     AFFECTING 
DISORDERS.  In  one  8vo  vol.  of  479  p.  Cloth,  S5.-25.  :  PRINCIPALLY    THE    ORGANS    OF    GENERA- 
LEE'S   LECTURES  ON   SYPHILIS  AND   SOME  ;  TION.     In  one  Svo.  vol.  of  i;4t3  pages.     Cloth,  §2.25. 


26 


Lea  Brothers  &  Co.'s  Publications — Diseases  of  Skin. 


SYDB,  J.  NEVINS,  A.  M.,  M,  D., 

Professor  of  Dermatology  and  Venereal  Diseases  in  Mush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students  and 
Practitioners.  In  one  handsome  octavo  volume  of  570  pages,  with  66  beautiful  and  elab- 
orate illustrations.     Cloth,  $4.25 ;  leather,  §5.25. 


The  author  has  given  the  student  and  practi- 
tioner a  work  admirably  adapted  to  the  wants  of 
each.  We  can  heartily  commend  the  book  as  a 
valuable  addition  to  our  literature  and  a  reliable 
guide  to  students  and  practitioners  in  their  studies 
and  practice. — Ant  Journ.  of  Med.  Sci.,  July,  1883. 

Especially  to  be  praised  are  the  practical  sug- 
gestions as  to  what  may  be  called  the  common- 
sense  treatment  of  eczema.  It  is  quite  impossible 
to  esasgerate  the  judiciousness  with  which  the 
formuiie  for  the  external  treatment  of  eczema  are 
selected,  and  what  is  of  equal  importance,  the  full 
and  clear  instructions  for  their  use. — London  Medi- 
cal Times  and  Gazette,  July  28, 1883. 

The  work  of  Dr.  Hyde  will  be  awarded  a  high 
position.  The  student  of  medicine  will  find  it 
peculiarly  adapted  to  his  wants.  Notwithstanding 
the  extent  of  the  subject  to  which  it  is  devoted, 
yet  it  is  limited  to  a  single  and  not  very  large  vol- 
ume, without  omitting  a  proper  discussion  of  the 
topics.  The  conciseness  of  the  volume,  and  the 
setting  forth  of  only  what  can  be  held  as  facts  will 
also  make  it  acceptable  to  general  practitioners. 
— Cincinnati  Medical  News,  Feb.  1883. 

The  aim  of  the  author  has  been  to  present  to  his 
readers  a  work  not  only  expounding  the  most 
modern  conceptions  of  his  subject,  but  presenting 
what  is  of  standard  value.  He  has  more  especially 
devoted  its  pages  to  the  treatment  of  disease,  and 
by  his  detailed  descriptions  of  therapeutic  meas- 
ures has  adapted  them  to  the  needs  of  the  physi- 


cian in  active  practice.  In  dealing  with  these 
questions  the  author  leaves  nothing  to  the  pre- 
sumed knowledge  of  the  reader,  but  enters  thor- 
oughly into  the  most  minute  description,  so  that 
one  is  not  only  told  what  should  be  done  under 
given  conditions  but  how  to  do  it  as  well.  It  is 
therefore  in  the  best  sense  "  a  practical  treatise." 
That  it  ia  comprehensive,  a  glance  at  the  index 
will  show. — Maryland  Medical  Journal,  July  7, 1883, 
Professor  Hyde  has  long  been  known  as  one  of 
the  most  intelligent  and  enthusiastic  representa- 
tives of  dermatology  in  the  west.  His  numerous 
contributions  to  tiie  literature  of  this  specialty 
have  gained  for  him  a  favorable  recognition  as  a 
careful,  conscientious  and  original  observer.  The 
remarkable  advances  made  in  our  knowledge  of 
diseases  of  the  skin,  especially  from  the  stand- 
point of  pathological  histology  and  improved 
methods  of  treatment,  necessitate  a  revision  of 
the  older  text-books  at  short  intervals  in  order  to 
bring  them  up  to  the  standard  demanded  by  the 
march  of  science.  This  last  contribution  of  Dr. 
Hyde  is  an  effort  in  this  direction.  He  has  at- 
tempted, as  he  informs  us,  the  task  of  presenting 
in  a  condensed  form  the  results  of  the  latest  ob- 
servation and  experience.  A  careful  examination 
of  the  work  convinces  us  that  he  has  accomplished 
his  task  with  painstaking  fidelity  and  with  a  cred- 
itable result. — Journal  of  Cutaneous  and  Venereal 
Diseases,  June,  1883. 


FOX,  T,,  M.D,,  F.M.  C.  JP.,  and  FOX,  T,  C,  B.A.,  M,JR,  aS., 


Physician  to  the  Department  for  Skm  Diseases, 
University  College  Hospital,  London. 


Physician  for  Diseases  of  the  Skin  to  the 
Westminster  Hospital,  London. 


An  Epitome  of  Skin  Diseases.  With  Pormul83.  For  Students  and  Prac- 
titioners. Third  edition,  revised  and  enlarged.  In  one  very  handsome  12mo.  volume 
of  238  pages.     Cloth,  $1 .25. 


The  third  edition  of  this  convenient  handbook 
calls  for  notice  owing  to  the  revision  and  expansion 
which  it  has  undergone.  The  arrangement  of  skin 
diseases  in  alphabetical  order,  which  is  the  method 
of  classification  adopted  in  this  work,  becomes  a 
positive  advantage  to  the  student.  The  book  is 
one  which  we  can  strongly  recommend,  not  only 
to  students  but  also  to  practitioners  who  require  a 
compendious  summary  of  the  present  state  of 
dermatology. — British  Medical  Journal,  July  2, 1883. 

We  cordially  recommend  Fox's  Epitome  to  those 
whose  time  is  limited  and  who  wish   a  handy 


manual  to  lie  upon  the  table  for  instant  reference. 
Its  alphabetical  arrangement  is  suited  to  this  use, 
for  all  one  has  to  know  is  the  name  of  the  disease, 
and  here  are  its  description  and  the  appropriate 
treatment  at  hand  and  ready  for  instant  applica- 
tion. The  present  edition  has  been  very  carefully 
revised  and  a  number  of  new  diseases  are  de- 
scribed, while  most  of  the  recent  additions  to 
dermal  therapeutics  find  mention,  and  the  formu- 
lary at  the  end  of  the  book  has  been  considerably 
augmented.— T%(3  Medical  News,  December,  1883. 


MOJEtMIS,  MALCOL3I,  M,  D., 

Joint  Lecturer  on  Dermatology  at  St.  Mary^s  Hospital  Medical  School,  London. 
Skin  Diseases ;  Including  their  Definitions,  Symptoms,  Diagnosis,  Prognosis,  Mor- 
bid Anatomy  and  Treatment.     A  Manual  for  Students  and  Practitioners.     In  one  12mo. 
volume  of  316  pages,  with  illustrations.     Cloth,  $1.75. 

for  clearness  of  expression  and  methodical  ar- 
rangement is  better  adapted'to  promote  a  rational 
conception  of  dermatology — a  branch  confessedly 
difficult  and  perplexing  to  the  beginner.— 5't  Louis 
Courier  of  Medicine,  April,  1880. 

The  writer  has  certainly  given  in  a  small  compass 
a  large  amount  of  well-compiled  information,  and 
his  little  book  compares  favorably  with  any  other 
which  has  emanated  from  England,  while  in  many 
points  he  has  emancipated  himself  from  the  stuD- 
bornly  adhered  to  errors  of  others  of  his  country- 
men. There  is  certainly  excellent  material  in  the 
book  which  will  well  repay  perusal. — Boston  Med. 
and  Surg.  Journ.,  Blarch,  1880. 


To  physicians  who  would  like  to  know  something 
about  skin  diseases,  so  that  when  a  patient  pre- 
sents himself  for  relief  they  can  make  a  correct 
diagnosis  and  prescribe  a  rational  treatment,  we 
unhesitatingly  recommend  this  little  book  of  Dr. 
Morris.  The  affections  of  the  skin  are  described 
in  a  terse,  lucid  manner,  and  their  several  charac- 
teristics so  plainly  set  forth  that  diagnosis  will  be 
easy.  The  treatment  in  each  case  i's  such  as  the 
experience  of  the  mosteminent  dermatologists  ad- 
vises.— Cincinnati  Medical  News,  April,  1880. 

This  is  emphatically  a  learner's  book;  for  we 
can  safely  say,  that  in  the  whole  range  of  medical 
literature  there  is  no  book  of  a  like  scope  which 


WILSON,  FBASMUS,  F,  M.  S. 

The  Student's  Book  of  Cutaneous  Medicine  and  Diseases  of  the  Skin. 

In  one  handsome  small  octavo  volume  of  535  pages.     Cloth,  $3.50. 

MILLIBR,  THOMAS,  M.  D., 

Physician  to  the  Skin  Department  of  University  College,  London. 
Handbook  of  Skin  Diseases ;  for  Students  and  Practitioners.    Second  Ameri- 
can edition.     In  one  12mo.  volume  of  353  pages,  with  plates.     Cloth,  $2.25. 


Lea  Brothers  &  Co.'s  Publications — Din.  of  Women.  27 


AJSr  AMERICAJSr  SYSTEM  OF  GYNMCOLOGY. 

A  System  of  Gynaecology,  in  TreatisofS  by  Various  Authors.  Editefl 
by  Matthew  D.  Manj^,  M.  ]>.,  I'roiessor  of  Obstetrics  an<l  Oyniccology  in  the  Uni- 
versity of  Bufialo,  N.  Y.  In  two  handsome  octavo  volumcH,  richly  illustrated.  In  (letive 
preparation. 

LIST  OF   CONTRIBUTORS. 

FORDYCE  BARKER,  M.  D.,  CHARLES  CARROLL  LEE,  M.  D., 

ROBERT  BATTEY,  M.  D.,  WILLIAM  T.  LUSK,  M.  D., 

SAMUEL  C.  BUSEY,  M.  I>.,  MATTHEW  T).  MANN,  M.  D., 

HENRY  F.  CAMPBELL,  M.  D.,  ROBERT  B.  MAURY,  M.  D., 

BEN.JAMIN  F.  DAWSON,  M.  D.,  C.  K.  PALMER,  M.  D., 

WILLIAM  GOODELL,  M.  D.,  WILLIAM  M.  POLK,  M.  L., 

HENRY  P.  GARRIGUES,  M.  D.,  THADDEUS  A.  REAMV,  M.  D., 

SAMUEL  W.  GROSS,  M.  D.,  A.  D.  ROCKWELL,  M.  £>., 

JAMES  B.  HUNTER,  M.  D.,  ALBERT  H.  SMITH,  M.  D., 

WILLIAM  T.  HOWARD,  M.  D.,  B.  STANSBURY  SUTTON,  A.  M,,  M.  D., 

A.  REEVES  JACKSON,  BI.  D.,  T.  GAILLARD  THOMAS,  M.  D., 

EDWARD  W.  JENKS,  M.  D.,  CHARLES  S.  WARD,  M.  D., 
WILLIAM  H.  WELCH,  M.  D, 


THOMAS,  T.  GAILLAJRD,  M.  J>., 

Professor  of  Diseases  of  Wo^nen  in  the  College  of  Physicians  and  Surgeons,  JV.  Y. 

A  Practical  Treatise  on  the  Diseases  of  Women.  Fifth  edition,  thoroughly 
revised  and  rewritten.  In  one  large  and  handsome  octavo  volume  of  810  pages,  with  266 
illustrations.     Cloth,  §;5.00;  leather,  |6.00;  very  hxindsome  half  Eussia,  raised  bands,  $6.50. 

The  words  which  follow  "fifth  edition"  are  in  i  vious  one.  As  a  boolc  of  reference  for  the  busy 
this  case  no  mere  formal  announcement.  The  I  practitioner  it  is  unequalled. — Boston  Medical  any 
alterations  and  additions  which  have  been  made  are  j  Surgical  Journal,  Apri  I  7, 1880. 

both  numerous  and  important.  The  attraction  j  It  has  been  enlarged  and  carefully  revised.  It  is 
and  the  permanent  character  of  this  book  lie  in  '  a  condensed  encyclopajdia  of  gynsecological  rnedi- 
tha  clearness  and  truth  of  the  clinical  descriptions  cine.  The  style  of  arrangement,  the  masterly 
of  diseases;  the  fertility  of  the  author  in  thera-  !  manner  in  which  eaeli  subject  is  treated,  and  the 
peutic  resources  and  the  fulness  with  which  the  j  honest  convictions  derived  from  probably  the 
details  of  treatment  are  described;  the  definite  j  largest  clinical  experience  in  that  specialty  of  any 
character  of  the  teaching;  and  last,  but  not  least,  j  in  this  country,  all  serve  to  commend  it  in  the 
the  evident  candor  which  pervades  it.  We  would  |  highest  terms  to  the  practitioner. — Nashville  Jour. 
also  particularize  the  fulness  with  which  the  his-    of  Med.  and  Surg.,  Jan.  1881. 

tory  of  the  subject  is  gone  into,  which  makes  the  i  "  That  the  previous  editions  of  the  treatise  of  Dr. 
book  additionally  interesting  and  gives  it  value  as  |  Thomas  were  thought  worthy  of  translation  into 
a  work  of  reference.— iondon  Medical  Tiihes  and  •  German,  French,  Italian  and  Spanish,  is  enough 
Gazette,  July  30, 1881.  to  give  it  the  stamp  of  genuine  merit.    At  home  it 

The  determination  of  the  author  to  keep  his  [  has  made  its  way  into  the  library  of  every  obstet- 
book  foremost  in  the  rank  of  works  on  gynsecology  i  rician  and  gynascologist  as  a  safe  guide  to  practice. 
is  most  gratifying.  Recognizing  the  fact  that  tliis  '  No  small  number  of  additions  have  been  made  to 
can  only  be  accomplished  by  frequent  and  thor-  the  present  edition  to  make  it  correspond  to  re- 
ough  revision,  he  has  spared  no  pains  to  make  the  j  cent  improvements  in  treatment. — Pacific  Medical 
present  edition  more  desirable  even  than  the  pre-  |  and  Surgical  Journal,  Jan.  1S81. 

EJyiS,  AMTHUM  W.,  M.  D.,  Zond.,  F,M,  C.  P.,  M,  M,  C.  S,, 

Assist.  Obstetric  Physician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  Hospital. 
The  Diseases  of  Women.     Including  their  Pathology,  Causation,  Symptoms, 
Diagnosis  and  Treatment.     A  Manual  for  Students  and  Practitioners.     In  one  handsome 
octavo  volume  of  576  pages,  with  148  illustrations.     Cloth,  |3.00 ;  leather,  |4.00. 

It  is  a  pleasure  to  read  a  book  so  thoroughly  [  The  greatest  pains  have  been  taken  with  the 
good  as  this  one.  The  special  qualities  which  are  i  sections  relating  to  treatment.  A  liberal  selection 
conspicuous  are  thoroughness  in  covering  the  j  of  remedies  is  given  for  each  morbid  condition, 
vrhole  ground,  clearness  of  description  and  con-  the  strength,  mode  of  application  and  other  details 
ciseness  of  statement.  Another  marked  feature  of  1  being  fully  explained.  The  descriptions  of  gjTiBe- 
the  book  is  the  attention  paid  to  the  details  of '  cologieal  "manipulations  and  operations  are  full, 
many  minor  surgical  operations  and  procedures,  j  clear  and  practical.  Much  care  has  also  been  be- 
as,  for  instance,  the  use  of  tents,  application  of  ■  stowed  on  the  parts  of  the  book  which  deal  with 
leeches,  and  use  of  hot  water  injections.  These  j  diagnosis — we  note  especially  the  pages  dealing 
are  among  the  more  common  methods  of  treat-  I  with  the  differentiation,  one  from  another,  of  the 
ment,  and  yet  very  little  is  said  about  them  in  '■  different  kinds  of  abdominal  tumors.  The  prac- 
many  of  the  text-books.  The  book  is  one  to  be  \  titioner  will  therefore  find  in  this  book  the  kind 
warmly  recommended  especially  to  students  and  I  of  knowledge  he  most  needs  in  his  daily  work,  and 
general  practitioners,  who  need  a  concise  but  com-  j  he  will  be  pleased  with  the  clearness  and  fulness 
plete  resume  of  the  whole  subject.  Specialists,  too,  '  of  the  information  there  given. — The  Practitioner, 
will  find  many  useful  hints  in  its  pages. — Boston  '  Feb.  1882. 
Med.  and  Surg.  Journ.,  March  2, 1882.  ■ 


BAMWES,  MOBEMT,  JSf.  D.,  F.  JR.  C,  JP., 

Obstetric  Physician  to  St.  Thomas'  Hospital,  London,  etc. 

A  Clinical  Exposition  of  the  Medical  and  Surgical  Diseases  of  Women. 

In  one  handsome  octavo  volume,  with  m;merous  illustrations.     Xew  edition.    Preparing. 

WEST,  CJETAMEES,  M.  D. 

Lectures  on  the  Diseases  of  Women.     Third  American  from  the  third  Lon- 
don edition.     In  one  octavo  volume  of  543  pages.     Cloth,  §3.75 ;  leather,  $4.75. 

CHURCHILL  ON  THE  PUERPERAL  FEVER  \  MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
AND  OTHER  DISEASES  PECULIAR  TO  WO-  i  3IENT  OF  CHILDBED  FEVER.  In  one  8vo. 
MEN.    InoneSvo.  vol.  of  464  pages.   Cloth,  $2.50.  |     volume  of  346  pages.    Cloth,  82.00. 


28         Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women,  Midwfy. 
EMMET,  THOMAS  ADniS,  M.  !>,,  LL,  D,, 

Surgeon  to  the  WomarCs  Hospital,  New  York,  etc. 

The  Principles  and  Practice  of  Gynseeology ;  For  the  use  of  Students  and 
Practitioners  of  Medicine.  New  (third)  edition,  thoroughly  revised.  In  one  large  and  very 
handsome  octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  ?5 ;  leather,  $6. 
{Just  ready.) 

Excerpt  from  the  Author's  Preface  to  the  Second  Edition. 

So  great  have  been  the  advance  and  change  of  views  during  the  past  four  years  in 
Gynseeology,  that  the  preparation  of  this  edition  has  necessitated  almost  as  much  labor  as 
to  have  rewritten  the  volume.  Every  portion  has  been  thoroughly  revised,  a  great  deal 
has  been  left  out,  and  much  new  matter  added. 

The  chapters  on  the  relation  of  education  and  social  condition  to  development,  those 
on  pelvic  cellulitis,  the  diseases  of  the  ovary  and  on  ovariotomy,  together  with  that  on 
stone  in  the  bladder,  have  been  nearly  rewritten. 

The  chapters  on  prolapse  of  the  vaginal  walls  and  lacerations  of  the  vaginal  outlet, 
the  methods  of  partial  and  complete  removal  of  the  uterus  for  malignant  disease,  the 
surgical  treatment  of  fibrous  tumors,  diseases  of  the  Fallopian  tubes,  and  the  diseases  of 
the  urethra,  are  essentially  new,  with  the  views  and  experience  of  the  author  in  a  form 
which  has  not  been  presented  to  the  profession  before.  To  these  chapters  not  less  than 
one  hundred  and  seventy-five  pages  of  new  material  have  been  added. 

endeavors  to  represent  the  actual  state  of  gynse- 
cologieal  science  and  art. — British  Medical  Jour- 
nal, May  IC,  1885. 

Any  work  on  gynseeology  by  Emmet  must 
always  have  especial  interest  and  value.  He  has 
for  ni any  years  been  an  exceedinglj^  busy  prac- 
titioner in  this  department.  Few  men  have  had 
his  experience  and  opportunities.  As  a  guide 
either  for  the  general  practitioner  or  specialist, 
it  is  second  to  none  other.  No  one  can  read 
Emmet  without  pleasure,  instruction  and  profit. 
— Cincinnati  Lancet  and  Clinic,  Jan  31,  1885. 


We  are  in  doubt  vchether  to  congratulate  the 
author  more  than  the  profession  upon  the  appear- 
ance of  the  third  edition  of  this  well-known  work. 
Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  conspicuously  distinguished  himself 
as  a  bold  and  successful  operator,  and  who  has 
devoted  so  much  attention  to  the  specialty,  we 
feel  sure  the  profession  will  not  fail  to  appreciate 
the  privilege  thus  offered  them  of  perusing  the 
views  and  practice  of  the  author.  His  earnestness 
of  purpose  and  conscientiousness  are  manifest. 
He  gives  not  only  his  individual    experience  but 


DVWCAW,  J.  MATTHEWS,  M.I^,,  LL,  D,,  F,  M.  S.  E.,  etc. 

Clinical  Lectures  on  the  Diseases  of  "Women ;  Delivered  in  Saint  Bar- 
tholomew's Hospital.     In  one  handsome  octavo  volume  of  175  pages.     Cloth,  $1.50. 

They  are  in  every  way  worthy  of  their  author  ; 
indeed,  we  look  upon  them  as  among  the  most 
valuable  of  his  contributions.    They  are  all  upon 


matters  of  great  interest  to  the  general  practitioner. 
Some  of  them  deal  with  subjects  that  are  not,  as  a 
rule,  adequately  handled  in  the  text-books;  others 
of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  leugtli  in  such  works,  yet  bear  such  a 


stamp  of  individuality  that,  if  widely  read,  as  they 
certainly  deserve  to  be,  they  cannot  fail  to  exert  a 
wholesome  restraint  upon  the  undue  eagerness 
with  which  many  young  physicians  seem  bent 
upon  following  the  wild  teachings  which  so  infest 
the  gynfeeology  of  the  present  day.— iV.  Y.  Medical 
Journal,  March,  1880. 


HOLfGE,  HVGHL.,  M.  D., 

Emeritus  Professor  of  Obstetrics,  etc.,  in  the  University  of  Pennsylvania. 
On  Diseases  Peculiar  to  Women;  Including  Displacements  of  the  Uterus. 
Second  edition,  revised  and  enlarged.     In  one  beautifully  printed  octavo  volume  of  519 
pages,  with  original  illustrations.     Cloth,  |4.50. 

By  the  Same  Author. 

The  Principles  and  Practice  of  Obstetrics.  Illustrated  with  large  litho- 
graphic plates  containing  159  figures  from  original  photographs,  and  with  numerous  wood- 
cuts. In  one  large  quarto  volume  of  542  double-columned  pages.  Strongly  bound  in 
cloth,  $14.00. 

*  ^  *  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by 
mail,  on  receipt  of  six  cents  in  postage  stamps. 

TARWLEM,    S.,    and    CHAWTMEJJIL,    G. 

A  Treatise  on  the  Art  of  Obstetrics.  Translated  from  the  French.  In 
two  large  octavo  volumes,  richly  illustrated. 

MAMSBOTHAM,.  EMAWCIS  H.,  3L  D. 

The  Principles  and  Practice  of  Obstetric  Medicine  and^  Surgery: 

In  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly  revised 
by  the  Author.  With  additions  by  W.  V.  Keating,  M.  D.,  Professor  of  Obstetrics,  etc., 
in  the  Jefferson  Medical  College  of  Philadeli^hia.  In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full-page  plates  and  43  woodcuts  in  the  text,  contain- 
ing in  all  nearly  200  beautiful  figures.     Strongly  bound  in  leather,  with  raised  bands,  $7. 

ASHWELL'S  PRACTICAL  TREATISE  ON  THE   |    American  from  the  third  and  revised  London 
DISEASES    PECULIAR    TU    WOMEN.     Third        edition.     In  one  8vo.  vol.,  pp.  520.    Cloth,  $3.50. 


Lea  BiurniKKS  &  ('(j.'k  Puijlicationk — Midwifery.  29 


PLAYFAIM,  W.  S.,  M.  T>.,  F,  It.  C.  P., 

Professor  of  ObnUdric  Medicine  in  Kiivfs  ColU<ic,  London,  etc. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  Now  (f<jnrth) 
American  edition,  revised  by  the  Autlior.  Edited,  witli  additionH,  hy  lUiV.VAVY  V,  JIar- 
KI3,  M.  1).  In  one  hiindsonic  octavo  volume  of  a))out  700  pages,  wilii  183  illustrations 
and  3  plates.     Cloth,  $4 ;  leather,  $5  ;  Jialf  Russia,  J)O.50.     Jwd  ready. 

A  few  notices  of  the  previous  e<iition  are  appended: 

of  tlio    .lubjoct   are    omitted. — CinclnnaU  Medicnl 


If  inqiiii'cd  of  hy  ft  medical  student  what  work 
on  obstetrics  wo  sliould  rocommcnd  for  liim,  par 
exceUcnce,  we  would  undoubtedly  advise  liim  to 
choose  I'layfaii-'s.  It  is  of  convenient  pizo,  but 
what  is  of  chief  importance,  its  treatment  of  the 
various  subjects  is  concise  and  plain.  While  the 
discussions  and  descriptions  are  suffieiently  elabo- 
rate to  reader  a  very  intoliigible  idea  of  them,  yet 
all  details  not  necessary  for  a  full  understanding 


News,  .Ian.,  1«S0. 

It  certainly  is  an  admirable  cxpofitfon  of  the 
science  and  practice  of  midwifery.  Of  course  ijics 
additions  made  iiy  the  American  editor,  Dr.  It.  P. 
Harris,  who  never  utters  an  idhs  wordj  and  whose 
studious  researches  in  some  special  (iepartments 
of  obstetrics  are  so  well  Isnown  to  the  profession,  are 
of  great  value. —  The  Amr.r.  J'raclitiontr,  April,  1880. 


BABKJER,  FOBDYCB,  A,  M.,  31.  D.,  LL.  Z>.  Fdin., 

C/ivlrnl  ]''rofr!<snr  (if  Miilivifrry  and  the  T)iseasrsof  )\''n'men  in  the  IJr./levtir,  Tfospi/nl  Mndiral  College, 
New  York,  i/unorary  Fellow  of  Ilia  Obn/ctrirai  Societies  of  London  and  liiUnhurrjIi,  etc.,  etc. 

Obstetrical  and  Clinical  Essays.    In  one  handsome  12mo.  volume  of  about 
300  pages.     Preparing. 

KING,  A.  F.  A.,  31.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 

A  Manual  of  Obstetrics.     New  edition, .   lu  one  very  liandsome  ]2mo.  volume 
of  331  pages,  with  59  illustrations.     Cloth,  $2.00. 

In  a  series  of  short  paragraphs  and  by  a  con-  correct  idea  of  them.  The  general  practitioner 
densed  style  of  composition,  the  writer  has  pre- 
sented a  great  deal  of  what  it  is  well  that  every 
obstetrician  should  know  and  be  ready  to  practice 
or  prescribe.  The  fact  that  the  demand  for  the 
volume  has  been  such  as  to  exhaust  the  first 
edition  in  a  little  over  a  year  and  a  half  speaks 
well  for  its  popularity. — American  Journal  of  the 
Medical  Sciences,  April,  1884. 

This  little  work  upon  obstetrics  viill  be  highly 
valued  by  medical  students.  We  feel  quite  sure 
that  it  will  be  in  great  demand  by  them,  so  suited 
is  it  to  their  want.s.  Of  a  size  that  it  can  be  easily 
carried,  yet  it  contains  all  of  the  main  points  in 
obstetrics  sufficiently  elaborated  to  give  a  full  and 


also  find  it  very  useful  fnr  reference,  for  the 
purpose  of  refreshing  the  mind.  We  can  confi- 
dently assert  that  it  will  be  found  to  be  the  best 
class  text-book  upon  obstetrics  tliat  has  been 
issued  from  tlie  press. — Cincinnati  Medical  News, 
March,  1884. 

It  must  be  acknowledged  that  this  i.s  just  what 
it  pretends  to  be — a  sound  guide,  a  portable  epit- 
ome, a  work  in  which  only  indispensable  matter 
has  been  presented,  leaving  out  all  padding  and 
chaff,  and  one  in  which  the  student  will  find  pure 
wheat  or  condensed  nutriment. — New  Orleans  Med- 
ical and  Surgical  Journal,  JMay,  1884. 


BAMNES,  IIOBFBT,  31.  B.,   and   FAWCOUBT,  31.  B., 

Phys.  to  the  General  Lying-in  IIosp.,  Land.  Obstetric  Phys.  to  St.  Thomas'  Hasp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  contributed  by 
Prof.  Milnes  Marshall.  In  one  handsome  octavo  volume  of  about  1000  pages,  profusely 
illustrated.    Cloth,  $5  ;  leathei-,  $6.      In  press. 

BABWFS,  FAWCOTIBT,  31.  B., 

Obstetric  Physician  to  St.  Thomas^  Hospital,  London. 

'  A  Manual  of  Midwifery  for  Midwives  and  Medical  Students.    In  one 
royal  12mo.  volume  of  197  pages,  with  50  illustrations.     Cloth,  $1.25. 

BABnJSr,  THFOBMILVS,  31.  B.,  LL.  B., 

Professor  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  the  Jefferson  Medical  College. 
A  Treatise  on  Midwifery.     In  one  very  handsome  octavo  volume  of  about  550 
pages,  with  numerous  illustrations.     In  press. 

BABBY,  JOHN  S.,  31.  B., 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-President  of  the  Obstet.  Society  of  Philadelphia. 
Extra  -  Uterine  Pregnancy:  Its   Clinical   History,   Diagnosis,   Prognocis   and 
Treatment.     In  one  handsome  octavo  volume  of  272  pages.     Cloth,  §2.50. 

TAKNEB.,  TII03IAS  MAJKKES,  31.  B. 

On  the  Signs  and  Diseases  of  Pregnancy.  First  American  from  the  second 
English  edition.  In  one  handsome  octavo  volume  of  490  pages,  with  4  colored  plates  and 
16  woodcuts.     Cloth,  |4.25. 


WIKCKEL,  F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  and  Practitioners.  Translated,  with  the  consent  of  the  Autlior,  from  the 
second  German  edition,  bv  James  Read  Chadwick,  M.  D.  In  one  octavo  volume  of  4S4 
p.'iges.     Cloth,  $4.00. 


30 


Lea  Brothers  &  Co.'s  Publications — J>Iidwfy.,  Dis.  CMlcln. 


LEISSMAN,  WILLIAM^M.  D., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  etc. 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  Third  American  edition,  revised  by  the  Author,  with  additions  by 
John  S.  Pakby,  M.  D.,  Obstetrician  to  the  Philadelphia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  pages,  with  205  illustrations.  Cloth,  |4.50 ;  leather, 
$5.50;  very  handsome  half  Russia,  raised  bands,  $6.00. 

preparation  of  the  present  edition  the  author  has 


The  author  is  broad  in  his  teachings,  and  dis- 
cusses briefly  the  comparative  anatomy  of  the  pel- 
vis and  the  mobility  of  tlie  pelvic  articulations. 
The  second  chapter  is  devoted  especially  to 
the  Soudy  of  the  pelvis,  while  in  the  third  the 
female  organs  of  generation  are  introduced. 
The  structure  and  development  of  the  ovum  are 
admirably  described.  Then  follow  chapters  upon 
the  various  subjects  embraced  in  the  study  of  mid- 
wifery. The  descriptions  throughout  the  work  are 
plain  and  pleasing.  Ifc  is  sufficient  to  state  that  in 
this,  the  last  edition  of  this  well-known  work,  every 
recent  advancement  in  this  field  has  been  brought 
forward. — Physician  and  Surgeon,  Jan.  1S80. 

We  gladly  welcome  the  new  edition  of  this  ex- 
cellent text-book  of  midwifery.  The  former  edi- 
tions have  been  most  favorably  received  by  the 
profession  on  both  sides  of  the  Atlantic.    In  the 


made  such  alterations  as  the  progress  of  obstetri- 
cal science  seems  to  require,  and  we  cannot  but 
admire  the  ability  with  which  the  task  has  been 
performed.  AVe  consider  it  an  admirable  text- 
book for  students  during  their  attendance  upon 
lectures,  and  have  great  pleasure  in  recommend- 
ing it.  As  an  exponent  of  the  midwifery  of  the 
present  day  it  has  no  superior  in  the  English  lan- 
guage.— Canada  Lancet,  Jan.  1880. 

To  the  American  student  the  work  before  us 
must  prove  admirably  adapted.  Complete  in  all  its 
parts,  essentially  modern  in  its  teachings,  and  with 
derruDustrations  noted  fo^r  clearness  and  precision, 
it  will  gain  in  favor  and  be  recognized  as  a  work 
of  standard  merit.  The  work  cannot  fail  to  be 
popular  and  is  cordially  recommended. — N.  O. 
Med.  and  Surg.  Journ.,  March,  18S0. 


SMITH,  J.  LBWIS,  M.  D,, 

Clinical  Professor  of  Diseases  of  CJiildren  in  the  Bellevue  Hospital  Medical  College,  N.  Y. 

A  Complete  Practical  Treatise  on  the  Diseases  of  Children.  Fifth 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  836  pages, 
with  illustrations.  Cloth,  $4.50 ;  leather,  |5.50 ;  very  handsome  half  Eussia,  raised  bands,  $6. 
"  '  which  we  venture  to  say  will  be  a  favorable  one. — 

Dublin  Journal  of  Medical  Science,  March,  1883. 

There  is  no  book  published  on  the  subjects  of 
which  this  one  treats  that  is  its  equal  in  value  to 
the  physician.  While  he  has  said  just  enough  to 
impart  the  information  desired  by  general  practi- 
tioners on  such  questions  as  etiology,  pathology, 
prognosis,  etc.,  he  has  devoted  more  attention  to 
the  diagnosis  and  treatment  of  the  ailments  which 
he  so  accurately  describes  ;  and  such  information 
is  exactly  what  is  wanted  by  the  vast  majority  of 
"  family  physicians." —  Va.  Med.  Monthly,  Feb.  1882. 


This  is  one  of  the  best  books  on  the  subject  with 
which  we  have  met  and  one  that  has  given  us 
satisfaction  on  every  occasion  on  which  we  have 
consulted  it,  either  as  to  diagnosis  or  treatment. 
It  is  now  in  its  fifth  edition  and  in  its  present  form 
ia  a  very  adequate  representation  of  the  subject  it 
treats  of  as  at  present  understood.  The  important 
subject  of  infant  hygiene  is  fully  dealt  with  in  the 
early  portion  of  the  book.  The  great  bulk  of  the 
work  is  appropriately  devoted  to  the  diseases  of 
infancy  and  childhood.  We  would  recommend 
any  one  in  need  of  information  on  the  subject  to 
procure  the  work  and  form  his  own  opinion  on  it, 


KBATING,  JOMWM,,  M.  D., 

Lecturer  on  the  Diseases  vf  Children  at  the  University  of  Pennsylvania,  etc. 

The  Mother's  Guide  in  the  Management  and  Feeding  of  Infants. 

one  handsome  12mo.  volume.of  118  pages.     Cloth,  $1.00. 


In 


Works  like  this  one  will  aid  the  physician  im- 
mensely, for  it  saves  the  time  he  is  constantly  giv- 
ing his  patients  in  instructing  them  on  the  sub- 
jects here  dwelt  upon  so  thoroughly  and  prac- 
tically. Dr.  Keating  has  written  a  practical  bookj 
has  carefully  avoided  unnecessary  repetition, -ana 
successfully  instructed  the  mother  in  such  details 
of  the  treatment  of  her  child  as  devolve  upon  her. 
He  has  studiously  omitted  giving  prescriptions, 
and  instructs  the  mother  when  to  call  upon  the 
doctor,  as  his  duties  are  totally  distinct  from  hers. 
— American  .Journal  of  Obstetrics,  October,  1881. 

Dr.  Keating  lias  kept  clear  of  the  common  fault 
of  works  of  this  sort,  viz.,  mixing  the  duties  of 
the  mother  with  those  proper  to  the  doctor.  There 
is  the  ring  of  common  sense  in  the  remarks  about 


the  employment  of  a  wet-nurse,  about  the  proper 
food  for  a  nursing  mother,  about  the  tonic  effects 
of  a  bath,  about  the  perambulator  versus  the  nurses, 
arms,  and  on  many  other  subjects  concerning 
which  the  critic  might  say,  "surely  this  is  obvi- 
ous," but  which  experience  teaches  us  are  exactly 
the  things  needed  to  be  insisted  upon,  with  theVich 
as  well  as  the  poor. — London  Lancet,  January,  28 1882 
A  book  small  in  size,  written  in  pleasant  style,  in 
language  whi  ch  can  be  readily  understood  by  any 
mother,  and  eminently  practical  and  safe;  in  fact 
a  book  for  which  we  have  been  waiting  a  long 
time,  and  which  we  can  most  heartily  recommend 
to  mothers  as  the  book  on  this  subject. — New  York 
Medical  Journal  and  Obstetrical  Review,  Feb.  1882. 


OWBW,  EDMJJWU,  31,  B.,  F,  M.  C.  S., 

Surgeon  to  the  Children's  Hospital,  Cheat  Orniond  St.,  London. 
Surgical  Diseases  of  Children.    In  one  12mo.  volume.    Preparing.    See  Series 
of  Clinical  Manuals,  page  3. 

WEST,  CMAMLES,  M,  D., 

Physician  to  the  Hospital  for  Sick  Cliildren,  London,  etc. 

Lectures  on  the  Diseases  of  Infancy  and  Childhood.    Fifth  American 
from  6tli  English  edition.   In  one  octavo  volume  of  686  pages.   Cloth,  $4.50 ;  leather,  $5.50. 

By  the  Same  Author. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood.    In  one  small 
12mo.  volume  of  127  pages.     Cloth,  $1.00. 


CONDIE'S   PRACTICAL    TREATISE    ON    THE 
DISEASES  OF  CHILDREN.    Sixth  edition,  re- 


vised and  augmented.    In  one  octavo  volume  of 
779  pages.    Cloth,  $5.25;  leather,  $6.25. 


Lea  Brothers  &  Co.'s  Publications — Med.  Juris.,  Miscel.         31 


TIBY,  CHARLBS  MEYMOTT,  M.  B,,  F,  C,  S,, 

Professor  of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  ike  London.  Hospital,  etc. 

Iiegal  Medicine.  Volume  II.  Legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Bape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birtli,  Infanticifie,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.  Making  a  very  handsome  imperial  oc- 
tavo volume  of  529  pago«.    Cloth,  $G.OO;  leather,  $7.00. 

Volume  I.  Containing  664  imperial  octavo  pages,  -with  two  beautiful  colored 
plates.     Cloth,  |6.00 ;  leather,  $7.00. 


The  satisfaction  expressed  with  the  first  portion 
of  tills  work  is  in  no  wise  lessened  by  a  perusal  of 
the  second  volume.  We  find  it  characterized  by 
the  same  fulness  of  detail  and  clearness  of  ex- 
pression whicli  wo  had  occasion  so  liighly  to  corn- 
mend  in  our  former  notice,  and  which  render  it  so 
valuable   to    the  medical   jurist.      The   copious 


tables  of  cases  appended  to  each  division  of  the 
subject,  must  have  cost  the  author  a  proditjious 
amount  'if  labor  and  research,  but  they  constitute 
one  of  the  most  valuable  features  of  the  book, 
especially  for  reference  In  medico-legal  trials. — 
American  Journal  of  the  Medical  Science)),  April,  1884. 


TAYLOR,  ALFRED  S.,  M.  D., 

Lecturer  on  Medicai  Jurisprudence  and  Chenmtry  in  Ouy^s  Hospital,  London. 

A  Manual  of  Medical  J^urisprudence.  Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.  Edited  by  John  J.  Keese,  M.  D.,  Professor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00 ;  leather,  $6.00 ;  half 
Russia,  raised  bands,  $6.50. 


The  American  editions  of  this  standard  manual  j 
have  for  a  long  time  laid  claim  to  the  attention  of  | 
the  profession  in   this  country;  and  the  eighth 
comes  before  us  as  embodying  the  latest  thoughts 
and  emendations  of  Dr.  Taylor  upon  the  subject  i 
to  which  he  devoted  his  life  with  an  assiduity  and  j 
success  which  made  him  facile  princeps  among  1 
English  writers  on  medical  jurisprudence.    Both  I 
the  author  and  the  book  have  made  a  mark  too 
deep  to  be  affected  by  criticism,  whether  it  be  j 
censure  or  praise.  In  this  case,  however,  we  should  | 


only  have  to  seek  for  laudatory  terms. — American 
Journal  of  the  Medical  Sciences,  Jan.  1881. 

This  celebrated  work  has  been  the  standard  au- 
thority in  its  department  for  thirty-seven  years, 
both  in  England  and  America,  in  both  the  profes- 
sions which  it  concerns,  and  it  is  improbable  that 
it  will  be  superseded  in  many  years.  The  work  i.3 
simply  indispensable  to  every  physician,  andnearly 
so  to  every  liberally-educated  lawyer,  and  we 
heartily  commend  the  present  edition  to  both  pro- 
fessions.— Albany  Law  Journal,  March  26, 1881. 


By  the  Same  Author. 

The  Principles  and  Practice  of  Medical  Jurisprudence.  Third  edition. 
In  two  handsome  octavo  volumes,  containing  1416  pages,  with  188  illustrations.  Cloth,  $10 ; 
leather,  $12.     Just  ready. 


For  years  Dr.  Taylor  was  the  highest  authority 
in  England  upon  the  subject  to  which  he  gave 
especial  attention.  His  experience  was  vast,  his 
judgment  excellent,  and  his  skill  beyond  cavil.  It 
is  therefore  well  that  the  work  of  one  who,  as  Dr. 
Stevenson  says,  had  an  "enormous  grasp  of  all 


matters  connected  with  the  subject,"  should  be 
brought  up  to  the  present  day  and  continued  In 
its  authoritative  position.  To  accomplish  this  re- 
sult Dr.  Stevenson  has  subjected  it  to  most  careful 
editing,  bringing  it  well  up  to  the  times. — Amerv- 
can  Journal  of  the  Medical  Sciences,  Jan.  1884. 


By  the  Same  Author. 

Poisons  in  Kelation  to  Medical  Jurisprudence  and  Medicine.  Third 
American,  from  the  6hird  and  revised  English  edition.  In  one  large  octavo  volume  of  788 
pages.     Cloth,  $5.50 ;  leather,  $6.50. 

FEFFER,  AUGUSTUS  J.,  M.  S,,  31.  B.,  F.  R.  C.  S., 

Examiner  in  Forensic  Medicine  at  the  University  of  London. 

Forensic  Medicine.  In  one  pocket-size  12mo.  volume.  Preparing.  See  Siudentf^ 
Series  of  Manuals,  page  3. 

LEA,  MENRY  C. 

Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  "Wager  of 
Battle,  The  Ordeal  and  Torture.  Third  revised  and  enlarged  edition.  In  one 
handsome  royal  12mo.  volume  of  552  pages.     Cloth,  $2.50. 


This  valuable  work  is  in  reality  a  history  of  civ- 
ilization as  interpreted  by  the  progress  of  jurispru- 
dence. .  .  In  "  Superstition  and  Force  "  we  h.ave  a 
philosophic  survey  of  the  long  period  intervening 
between  primitive  barbarity  and  civilized  enlight^ 
enment.    There  is  not  a  chapter  in  the  work  that 


should  not  be  most  carefully  studied ;  and  however 
well  versed  the  reader  may  be  in  the  science  of 
jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of  so- 
cial science. —  Westminster  Review,  Jan.  1880. 


By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 


efit of  Clergy — Excommunication, 
octavo  volume  of  605  pages.     Cloth,  $2.50. 

The  author  is  pre-eminently  a  scholar.  He  takes 
up  every  topic  allied  with  the  leading  theme,  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  of  information 
compressed  into  the  book  is  extraordinary.  In  no 
other  single  volume  is  the  development  of  the 


New  edition.    In  one  very  handsome  royal 

Just  ready. 

primitive  church  traced  with  so  much  clearness, 
and  with  so  definite  a  perception  of  complex  or 
conflicting  sources.  The  fifty  pages  on  the  growth 
of  the  papacy,  for  instance,  are  admirable  for  con- 
ciseness and  freedom  from  prejudice. — Boston 
T)-aveUer,  May  3, 1SS3. 


Allen's  Anatomy  .... 

American  Journal  of  the  Medical  Sciences 

American  System  of  Gynajcology    . 

American  System  of  Practical  jiledicine 

*Ashhurst's  Surgery     .... 

Ash  well  on  Diseases  of  Women 

Attfield's  Chemistry      .... 

Ball  on  the  Bectum  and  Anus 

Barker's  Obstetrical  and  Clinical  .Essaj's, 

Barlow's  Practice  of  Medicine 

Barnes'  Midwifery 

*Barnes  on  Dise'ases  of  Women 

Barnes'  System  of  Obstetric  Medicine 

Bartholow  on  Electricity 

Basham  on  Renal  Diseases    . 

Bell's  Comparative  Pliysiology  and  Anatomy 

Bellamy's  Operative  Surgery 

Bellamy's  Sui'gical  Anatomy 

Blandford  on  Insanity  , 

Bloxam's  Cliemistry      .  ,        . 

Bowman's  Practical  Chemistry 

*Bristowe's  Practice  of  Medicine    , 

Broadbent  on  the  Pulse 

Browne  on  tlie  Ophthalmoscope 

Browne  on  the  Throat  .  .  .    • 

Bruce's  Materia  Medica  and  Tlierapeutics 

Brunton's  Materia  Medica  and  Therapeutics 

Bryant  on  the  Breast    .... 

*Bryanl's  Practice  of  Surgery 

*Bumstead  on  Venereal  I)iseases    , 

*Burnett  on  the  Ear       ,         .  .  . 

Butlin  on  the  Tongue    .... 

Carpenter  on  the  Use  and  Abu.se  of  Alcoliol 

*Carpeuter's  Human  Physiology    . 

Carter  on  the  Eye  .... 

Centurj^  of  American  Medicine 

Chambers  on  Diet  and  Regimen 

Charles'  Physiological  and  Pathological  Chem, 

Churchill  on  Puerperal  Fever 

Clarlieand  Lockwood's  Dissectors'  Manual 

Classen's  Quantitative  Analysis 

Cleland's  Dissector 

Clouston  on  Insanity 

Clowes'  Practical  Chemistry 

Coats'  Pathology  .... 

Cohen  on  the  Throat     .... 

Coleman's  Dental  Surgery 

Condie  on  Diseases  of  Children 

Cooper's  Lectures  on  Surgery 

Cornil  on  Syphilis  .... 

*Cornil  and  Ranvier's  Pathological  Histology 

Cullerier's  Atlas  oi  Venereal  Diseases 

Curnow's  Medical  Anatomy 

Dalton  on  the  Circulation 

*Dalton's  HumanPhysiology 

Dalton's  Topographical  Anatomy  of  the  Brain 

Davis'  Clinical  Lectures 

Draper's  Medical  Physics 

Druitt's  Modern  Surgery 

Duncan  on  Diseases  of  Women 

*Dunglison's  Medical  Dictionary    . 

Edis  on  Diseases  of  Women    . 

Ellis'  Demonstrations  of  Anatomy 

Emmet's  Gynsecology 

*Erichsen's  System  of  Surgery 

Esmarch's  Early  Aid  in  Injuries  and  Accid'ts 

Farquharson's  Therapeutics  and  Mat.  Med. 

Fenwick's  Medical  Diagnosis 

Finlayson's  Clinical  Diagnosis 

Flint  on  Auscultation  and  Percussion 

Flint  on  Phthisis  .... 

Elint  on  Physical  Exploration  of  the  Lungs 

Flint  on  Respiratory  Organs 

Flint  on  the  Heart 

*Flint's  Clinical  Medicine 

Flint's  Essays       .  .  .  • 

♦Flint's  Practice  of  Medicine 

Folsom's  Laws  of  V.  S.  on  Custody  of  Insane 

Foster's  Physiology       .... 

♦Fothergill's  Handbook  of  Treatment     . 

Fownes'  Elemeniary  Chemistry 

Fox  on  Diseases  of  the  Skin  . 

Frankland  and  Japp's  Inorganic  Chemistry 

Fuller  on  the  Lungs  and  Air  Passages 

Galloway's  Analysis     .... 

Gibney's  Orthopaedic  Surgery 

Gibson's  Sui-gery  .... 

Gluge's  Pathological  Histology,  by  Leidy 

Gould's  Surgical  Diagnosis 

*Gray's  Anatomy  ... 

Greene's  Medical  Chemistry  . 

Green's  Patliologj'  and  Moi'bid  Anatomy 

Grithlh's  Universal  Formulary 

Gross  on  Foreign  Bodies  in  Air-Passages 

Gross  on  Impotence  and  Sterility    . 

Gross  on  Urinary  Organs 

*Gross'  System  of  Surgery 

Habershonon  the  Abdomen 

♦Hamilton  on  Fractures  and  Dislocations 

Hamilton  on  Nervous  Diseases 

Hartshorne's  Anatomy  and  Ph.vsiology  . 

Hartshorne's  Conspectus  of  thelNIed.  Sciences 

Hartshorne's  Essentials  of  Medicine 

Hermann's  Experimental  Pharmacology 

Hill  on  Syphilis  ..... 

Hillier's  Handbook  of  Skin  Diseases 

Hoblyn's  Medical  Dictionary 

Hodge  on  Women         .... 

Books  marked  * 


6 
3 

27 
15 
20 
28 
9 
21 
29 
17 
29 
27 
29 
17 
24 
3,7 
3,20 
6 
19 


14 

3,16 

23 

■18 

11 

11 

3,21 

21 

25 

24 

3,21 


23 
14 
17 

10 
27 

6 
10 

5 
19 
10 
13 
18 
24 
30 
20 
25 
13 
25 
3,6 

7 

8 

7 
16 

7 
21 
28 

4 
27 

7 
28 
21 
21 
12 
16 
16 
18 
18 
18 
18 
18 
16 
16 
14 
19 

8 
16 

8 
26 

9 
18 

3 
20 
20 
13 
3,20 

5 
10 


Hodge's  Obstetrics         .... 

Hotlmann  and  Power's  Chemical  Analysis 

Holden's  Landmarks    .... 

Holland's  Medical  Notes  and  Reflections 

*Holmes'  System  of  Surgery    - 

Horner's  Anatomy  and  Histology 

Hudson  on  Fever 

Hutchinson  on  Syphilis 

Hj'de  on  the  Diseases  of  the  Skin    . 

Jones  (C.  Handfield)  on  Nervous  Disorders 

Juler's  Ophthalmic  Science  and  Practice 

Keating  on  Infants 

King's  Manual  of  Obstetrics    . 

Klein's  Histology 

La  Roche  on  Pneumonia,  Malaria,  etc. 

La  Roche  on  Yellow  Fever    . 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye,  Orbit  and  Eyelid 

Lea's  Studies  in  Church  History 

Lea's  Superstition  and  Force 

Lee  on  Syphilis 

Lehmanli's  Chemical  Physiology 

*Leishman's  Midwifery  .  . 

Lucas  on  Diseases  of  the  Urethra 

Ludlow's  Manual  of  Examinations 

Ijyons  on  Fever   . 

Maisch's  Organic  Materia  Medica 

Marsh  on  the  Joints 

Medical  News 

Meigs  on  Childbed  Fever 

Miller's  Practice  of  Surgery   . 

Miller's  Principles  of  Surgery 

Mitcliell's  Nervous  Diseases  of  Women 

Morris  on  Diseases  of  the  Kidneys 

Morris  on  Skin  Diseases 

Neill  and  .Smith's  Compendium  of  Med.  Sci. 

Nettieship  on  Diseases  of  the  Eye  . 

Owen  on  Diseases  of  Children 

*Parrish's  Practical  Pharmacy 

Parry  on  Extra-Uterine  Pregnancy 

Parvin's  Midwifery 

Pavy  on  Digestion  and  its  Disorders 

Pepper's  Forensic  Medicine   . 

Pepper's  Surgical  Pathology 

Pick  on  Fractures  and  Dislocations 

Pirrie's  System  of  Surgery 

Playfair  on  Nerve  Prostration  and  Hysteria 

*Playfair's  Midwifery  . 

Politzer  on  the  Ear  and  its  Diseases 

Power's  Human  Physiology  . 

Ralfe's  Clinical  Chemistry 

Ramsbotham  on  Parturition 

Remsen's  Theoretical  Chemistry    . 

*Reynolds'  System  of  Medicine 

Richardson's  Preventive  Medicine 

Roberts  on  Urinary  Diseases 

Roberts'  Principles  and  Practice  of  Surgery 

Robertson's  Physiological  Physics 

Rodwell's  Dictionary  of  Science 

Sargent's  Minor  and  Militarj'  Surgery 

Savage  on  Insanity,  including  Hysteria 

Schafer's  Essentials  of  Histology, 

Schafer's  Histology 

Schreiber  on  Massage   . 

Seller  on  tlie  Throat,  Nose  and  Naso-Pharynx 

Series  of  Clinical  Manuals 

Simon's  Manual  of  Chemistry 

Skev's  Operative  Surgery 

Slade  on  Diphtheria 

Smith  (Edward)  on  Consumption 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas 

*Smith  (J.  Lewis)  on  Children 

StlUe  on  Cholera  ... 

*Stillfi  &  Maisch's  National  Dispensatory 

*Still6's  Therapeutics  and  Materia  Medica 

Stimson  on  Fractures   .... 

Stimson's  Operative  Surgery 

Stokes  on  Fever  ..... 

Students' Series  of  Manuals   . 

Sturges'  Clinical  Medicine 

Tanner  on  Signs  and  Diseases  of  Pregnancy 

Tanner's  Manual  of  Clinical  Medicine     . 

Tarnier  and  Chantreuil's  Obstetrics 

Taylor  on  Poisons  .... 

*Taylor's  Medical  Jurisprudence    . 

Taylor's  Prin.  and  Prac.  of  Med.  Jurisprudence 

*Thomas  on  Diseases  of  Women 

Thompson  on  Stricture 

Thompson  on  Urinary  Organs 

Tidy's  Legal  Medicine .... 

Todd  on  Acute  Diseases 
13  I  Treves' Applied  Anatomy 
n    Treves  on  Intestinal  Obstruction     . 

Take  on  the  Influence  of  Mind  on  the  Body 

Walshe  on  the  Heart    .... 

Watson's  Practice  of  Physic  . 

*Wells  on  the  Eve         .... 

West  on  Diseases  of  Childhood 

Weston  Diseases  of  Women 

West  on  Nervous  Disorders  in  Childhood 

V/illiarns  on  Consumption     . 

Wilsons  Handbook  of  Cutaneous  Medicine 

AVilson's  Human  Anatomy    . 

Wiiickel  on  Pathol,  and  Treatment  of  Childbed 

Wiihler's  Organic  Chemistry 

Wood  head's  Practical  Pathology 

Year-Book  of  Treatment 


28 
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